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Secound
Edition

7 ea =m |
3 fTcle

Histology
 TABLE OF CONTENTS

ENAMEL.....

DENTINE...

DENTALPULP.....

CEMENTUM.......

PERIODONTAL LIGAMENT ..

ALVEOLARBONE..

ORAL MUCOSA1 .... 112

ORAL MUCOSA2 .... 138

ORAL EMBRYO... 161

EARLY TOOTH DEVELOPMENT.. 191

SALIVARY GLAND 215

TEMPOROMANDIBULARJOINT .. 238
 Enamel 1
Enamel
The outline:

1) Physical properties.

2) Chemical properties. Enamel

Af
3) Histological structure of enamel. \
Ze _——Dentin
4) Age changesin enamel.

5) Clinical consideration.

Physical properties
The picture beside is a longitudinal section of a molar. ‘Cementum
Asit showsthe crown is covered with enamel while
the roots are covered with cementum.

- The thickness of enamel varies from up to 2.5mm (1.3 in primary teeth) over
cusps or incisal edge (highest thickness) to feather edge at cervical margins
(lowest thickness, Also the thickness of cementum in the cervical area is the
lowest). So the thickness of enamel in the deciduous teeth is about the half
of it at permanent.
- It is the hardesttissue.
- Withstands shearing and impact forces and has a high resistance to abrasion.
- It CANNOTberepaired or replaced.
- Itis brittle, so requires the supportofthe resilient dentine (for the
cushioning effect). Soit’s like glass very hard but can be broken easily.

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 evant
- Low tensile strength but high modulus ofelasticity. Which means it’s hard.

- Surface enamel is harder, denser and less porous than subsurface enamel. So
the deeper we go in enamel the less hard & denseit becomes.
- Hardness and density decrease from the cusp tips to the cervical margins.
Whichis logical as the oclosal loads is centered on the cusp tips & incisal
edges,as they are the functional areas where the margin is less subjected to
the loads.
- Young enamel (of newly erupted teeth) appears white turning to a more
yellow appearance(in elderly) as translucency increases with age. As the
newly erupted teeth can mask the yellowish color of the dentine and with
aging it becomes moretranslucent which can showthe yellow color of the
dentine.

Chemical properties
Enamel is composed of 96% inorganic components(mineral), 2% organic
(proteins) component and 2% water by weight.

- Inorganic composition:
Calcium hydroxyapatite Caio(PO.)s(OH)2 is the principal mineral component
of enamel which is formed by calcium, phosphate & hydroxyl. It is present in
the form ofcrystallites.

- Organic composition:
Free amino acids, small molecules, peptides and large protein complexes
(amelogenins and non-amelogenins).

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 Hydrox'
- Mostcrystallites are hexagonal in cross section.

- Enamelhydroxyapatite crystals are about 70nm in

width, 25nm thick and ofgreat length (almost the full
thickness of enamel). So the length differs from area
to another depending on the thicknessand it reaches
the highest at the cusp tips & the lowestat the cervical
margins.

- The coresof the crystals are richer in magnesium and carbonatein

comparison to the peripheries. This happens because of mineral substitution
when thereis deficiency of the basic minerals, so mostly in the core the
magnesium substitute the calcium & the carbonate substitute the
phosphate. But the body tries to makethe substitution reactions in the
peripheries less than in the core to makeit harder, so the core is more
soluble.

- Each crystal unit has a hydroxyl group surrounded by eeSTL

3 calcium ions which are surrounded by 3 phosphate
ions. Six calcium ions in a hexagon enclose the
phosphateions. So we have two typesofcalcium:
screw axis Ca in the Center & columnar Cain the_
periphery.

- The crystal is made of a repetition of those planes of

ions side byside in stackedlayers.

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 = Substitutions in the Hydroxyapatite Crystals

The main substituents of human apatite are:

- 1- Hydroxyl phosphate (HPOs) and carbonate (COs) for phosphate (PO,).
- 2- Strontium (Sr), barium (Ba), lead (Pb), sodium (Na), potassium (K) and
magnesium (Mg) for calcium (Ca).
- 3- fluoride (F), chloride (Cl), broom (Br) and iodide (I) for hydroxyl (OH).

- The ions present in enamel may influence dental caries by affecting the
dissolution of the apatite crystals and/or affecting remineralisation.

- Fluoride’s incorporation in the crystal inhibits caries, and it’s the only
substituent that makesthe crystal harder, so because ofthat wefind it in
toothpastes. Butthe problem that it causes cytotoxicity so it’s advised notto
use these toothpastesfor children and for adults notto swallowit.

- Carbonate’s incorporation in the crystal promotesthe carious attack. Which

is mostly present in soft drinks.

Water

- 2% by weight, 5-10% by volume.

- Water presenceis related to the porosity of the tissue. So where ever there
is pours thereis water.

- Might be present between the crystals surrounding the organic component.

- Might be trapped within crystalline defects forming a hydration layer.

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 Fluoride ions & all the ions mentioned beforetravel through the water
component. So the substitution doesn’t happen in the peripheries only but
also in the deep layers.

Organic ma‘

Mature enamel 1-2% (commonrange); varies from 0.05% to 3% (extreme

values) depending on the regularity of the crystals. So the more regular the
crystals the less organic matrix is found. (If asked in the exam what is the
common percentageof organic matrix in mature enamel the answer will be
2%).
= The 2% includes:
1- 50-90%: small molecules; peptides and free amino acids particularly
glycine and glutamic acid.
2- Larger protein complexes: of amelogenins and non-amelogenins. Types of
non-amelogenins: enamelins & tuftelin & ameloblastin. The only type of
amelogenins is amelogenin.

The highest concentration of proteins in enamel is in tufts at the dentine-

enamel junction.
Larger molecular weight components contain componentsrich in
carbohydrates.
Lipid content 1% by weight of enamel. May represent remnantsofcell
membranes.
Proteins and peptides accountfor less than 2% of mature enamel weight and
25-30% of early enamel. So the organic matrix in early enamel is higher.
The bulk of the developing enamel matrix (90-95%) is the protein
amelogenin produced by ameloblasts. Then most of these amelogenins is
substituted with minerals in process we call MATURATION which happens
before teeth eruption.

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 Amolegenins
- Hydrophobic and tend to aggregate into clumps.
- They spread throughout the whole developing enamel resulting in a gel
matrix through which molecules and ions spread readily.
- This helpsin the formation oflarge crystals.

Non-amelogenins(such astuftelin)
- May be derived from plasma albumin
- Contain distinct components secreted by ameloblasts.
- They may havea role in mineralization.

Histology
There are twotypes ofhistological sections:

1- Demineralized (decalcified): where the minerals are removed. But in this

typecells remain a life.
2- Ground section: wherethe tissue is cut as it is without removing minerals,
butcells aren’t kepta life.

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 -Due to its high mineral -Enamelstructure is Immature enamel
content (96%) enamel is mainly studied in can be studied in
totally lost in ground sections. demineralized
demineralized sections. sections due to its
high protein content
| (25-30%) |
Junctional " f
Dentin Stellate
Enamel *
yfeticulum

** In immature enamel:
Organic matrix= 25-30%
Inorganic content= 70- 75%
Enamelprisms
Prisms (rods) are the basic structural units (building block) of enamel.
Each prism consists of several million hydroxyapatite crystals packed into a long
thin rod 5-6um in diameter and up to 2.5mm in length (as this is the highest
possible length of enamel).

They have divided the enamel into quarters depending on the orientation of
prisms:

1) The outer most(20-100um primary teeth and 20-70um secondary teeth) is

aprismatic which means it doesn’t haveprisms just crystals.
-The crystallites are aligned at right angles to the surface and parallel to each
other.
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 Enamel

-The surface layer is more highly mineralized than the rest of the enamel.
** This is attributed to the absenceof prism boundaries where organic
material is located.
2) In The outer 1/4"all prisms run in the same direction and so thereis no
banding.
3) In the inner 3 1/4" the prisms have banding
pattern.
Dentin
Every 10-13 layersof prisms follow the same
direction, but blocks above and belowfollow
paths in different directions.
This gives rise to a banding patterncalled the
Hunter-Schregerbands.
They are approximately 502m in width and
are visible due to light reflection in different
directions.

4) The inner most is aprismatic, but the crystals are distributed randomly.

Theprismsin the pic have 2 different

— orientationsin bands pattern, thisis called
Hunter-Schreger bands which is foundin the
3/4" of enamel. This pattern increases the
hardness to withstandthe occlusionforces.

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Enamel prisms in cross section

Prisms in cross section appear in different patterns, but

the keyhole pattern (pattern III) predominates.

Prisms have head and tail regions. The tail of one prism
lies between the heads of the two adjacentprisms.

- An abrupt changeofcrystal orientation at the prism

boundary is responsible for the optical appearance
In this pic the prisms are in one
of the boundary. direction so this section is taken from
the upper1/4" of enamel
- The crystals in the head ofthe prism run parallel tothe
long axis of the prism.
- In the tail, the crystals diverge gradually to become
angled at 65-70° to the long axis.

- The change from head totail is gradual in each prism,

however a tail of one prism showsa sudden divergence
from the head of an adjacent prism.

A variation of prism shape might be encounteredin cross sections. This is

dependent on the angle at which the section was cut. So if we cut at 90° the result
will be a perfect keyhole shaped prism while if cut at 0° will result in rectangular,
and in between will result in elongated keyhole.

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- Prisms are separated by inter-rod substance. Crystals
with different orientation (deviate by 40-60°). Actually
what is called inter-rod substance is tail of the
neighboring rod.

- Prism boundaries reflect a sudden changein crystallite

orientation.

- Slightly undulating course (deviation to the main course)

that reflects ameloblast path during secretion. So if the
ameloblast wentin a straight pathway the prism will
look straight.
So to sayit correctly thethingin
thepic calledrod is a rod’s head
while what's called inter-rod is a
tail ofa neighboring rod.

Prisms over the cusps appear twisted around |

each other in a complex arrangement known
as gnarled enamel. This happens because of |
the crowding of the ameloblasts which make
it hard toit to run in straightlines. ,

Incremental lines
Enamelis formed in increments: periods ofactivity alternating with periods
ofinactivity.
This results in incremental lines: short period “daily incremental lines”called
(cross striations) and long period “weekly incremental lines” called (enamel
striae).
= The crossstriation
Crossstriations appear as lines crossing the enamel prisms at right anglesto
their long axes. (so they make 90° angle with the prisms.
Theyreflect a diurnal rhythm (daily increments of growth).
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a
- They appear as lines 2.5-6um apart (which represent the space between
lines).
- Closer to each other near the enamel-dentine junction. And becomes further
to each other when running away from the junction.
- Explanations of why theselinesdiffer of each other from area to another:
Variations in the organic matrix. Crystal orientation and composition??

= Enamelstriae
- Enamelstriae run obliquely across the prisms. They
represent incremental lines and are known as the_
Striae of Retzius. In longitudinal section _—

- Incross sections, the striae of Retzius run

circumferentially like the rings of a tree.
- There are 7-10crossstriations between
enamel adjacentstira.
- This suggests weekly intervals.
- Enamelstria are 25-35um apart in the middle
portion (crossstriations 44m apart), while they
are 15-20um apart cervically (crossstriations
2um apart).
The amount of enamel excreted (daily or weekly) in
middle portion is more than in cervical areas (The
slowest area in enamel excretion).

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 Enamel

On the surface, the stria appear as fine grooves

running circumferentially around the crown. It
appearslike this only in newly erupted teeth then
it disappears due to teeth attrition.
The lines are termed Perikymata grooves, with
perikymata ridges in between.

If thereis a line that looks more prominent than

other then:
1) If found on a primaryteeth or first permanent
molarthen it’s called Neonatal line; which is formed due tobirth. So it
divides the enamel formed after birth of the one formed before.
2) If found in other teeth then called Willson band; which demarcates one of
twocases: 1-childhoodillness with high temperature. OR 2-bad nutrition.

= Enamel surface
The properties of surface enamel:
1- Physically and chemically, surface enamel differs from subsurface enamel.
2- Surface enamel is harder, less porous, less soluble and moreradio-
opaque.
3- Richer in trace elements.
4- Less carbonate.
5- Aprismatic, therefore highly mineralized. (We said before prisms form due
to different direction of crystals in certain way. Soifall the crystals run in
the same way it won’t haveprisms).
 = Enamelsurface landmarks:
1) Enamel pits:
- On protected areas of enamel, small pits could
be seen onthe surface.
- The pits are within the perikymata ridges.
- They markthe ends of ameloblasts(soit’s called
prism end markings or ameloblast marking). It’s
formed before eruption where enamel is
covered with ameloblasts which leaves mark
later.
Enamelpits and perikymata, can be seen in
newlyerupted teeth as after period of time they
will disappear becauseofattrition.
- 1-1.5ym in depth.

2) Enamel caps:
- They are small elevations 10-15um
across. So they are opposite of enamel
pits.
- They result from mineral deposition on
top of debris late during tooth
development.(in other words they form
due to precipitation minerals on the top
of remains organic materials).

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 Enamel S
3) Focalholes:
- They are depressions on the surface. But
they are larger than the pits.
- Loss of enamel caps with the underlying
material.
This happens through:
1) Abrasion: non physiological process
usually done by hard tooth brush. ,
Or 2) Attrition: is the normal physiological ss
loss of enamel which is done by food
mastication.
(Another term of enamel loss is erosion
which means losing enamel by acids by demineralization).

4) Enamelbrochs:
- They are elevations on the enamel
surface contain radiating or random
groups ofcrystals. (So it’s an added
amounts on the normal surface).
- Diameter=30-50um.
- More common in premolars.

« Enamel-dentine junction
The pattern of the junction depends on the forces exposedto the area:
- It has a scalloped where shearing forces would be high (beneath
cuspsand incisal edges). This pattern increases the connection between
enameland dentine to withstand the forces.
- The junction is smooth (straight) in /ateral surfaces.

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 = Landmarkson the enamel-dentine junction:
1) Enamel spindle:
- Narrow, round tubules 8um in diameter.
They extend up to 25m into the enamel.
- Someexplanations of howit formed ENAMEL
1- When small part of dentinal tubules
(that located in dentine) reaches the
enamel.
2- Odontoblastic processes among
ameloblasts. In the beginning of
developmentof teeth there are a layer
of ameloblasts and a layer of
odontoblasts and they should not
enter between each other, but when
odontoblasts processes get between ameloblast (due to crowding)
enamel spindle formation will occur.
3- Enamel Remnants of dead odontoblasts OR dentinal collagen.
So generallyit’s is from dentine.
- Most commonly beneath cusps & incisal edges. (Because they are the place
of crowding).

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 2) Enameltufts
Junctional structuresin the inner third of
enamelthat resemble tufts of grass
(Lookslike tree branching). They have the same
direction as enamel prisms.
- Recur at 100umintervals.
- They are hypo mineralized and thoughtto be
residual matrix protein at the prism boundaries.
- Tuft protein is a minor non-amelogenin protein;
which is a common protein in enamel tufts & Dentino-enamel
junction
thought toparticipate in mineralization process.

3) Enamel lamella
Structural faults that run through the entire
thickness of the enamelto reach the surface or
just belowit, and it’s a hypomineralized areas.
- It may arise due to incomplete maturation of
groups ofprisms.
- Should not be confused with cracks produced
during ground section preparation. To
differentiate between them weshould do a
demineralized sectionifit’s still there thenit’s
an enamellamellaif notit’s a crack.

v TO differentiate between the 3 types remember the following:

1- Enamel spindle is the shortest type and it’s NOT branched
2- Enamel tufts is longer than the spindle and it is branched.
3- Enamellamella run the entire thickness of enamelto the surface or
just below it. Also rememberhowtodiffer betweenit & cracks.

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emt
¢ Enamel Microporosity
- Enamelpores are water filled spaces between the crystallites. It makes 3-5%
by volume. And the pores are Larger at prism boundaries.

= Cement-enamel juncyion
Three arrangements between cementum and
enamelcan be seen:
- Pattern 1: the cementum overlaps the enamel,
60%).
- Pattern 2: the cementum and enamel meetat butt
joint (called edge to edge) (30%).
- Pattern3: cementum and enamel fail to meet and
the dentine between them is exposed (10%).
- Allthese patterns may bepresentin a Single tooth.

Age changes
Enamel wears slowly with age depending on diet and habits.

Teeth darkens in color with aging due to:

1- Reduced translucencyof the tooth as secondary dentine forms and enamel

thins. (While the translucency of enamel increases with aging so the
underlying yellow dentine layer starts to appear which makesthe tooth
looks darker & more yellowish).
2- Accumulation of surface coatings and stains.

The composition of surface enamel changesas a result of exchanges with the

oral fluids.

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Thereis a decrease in caries in elders due to:

1- Enhanced mineralization.
2- The loss of tooth structure due to periodontal disease. Howthis is related to
decreasing caries? This because when one tooth is lost the chanceof bacteria
accumulation in this large space is very low comparingto the chance of
accumulation in the space between twoadjacentteeth.
3- The lower intake of carbohydrates.
4- The smoothening ofplaque retaining areas by attrition. As the pits and
grooves ofthe tooth aresuitable areas for caries.

Clinical consideration
1) Enamel defects:
Developmental defects present in 68-95% of the population.
- Causes: Environmental or genetic.
“ Environmental :
1- Fluorosis: the amount offlour in water shouldn’t be higher than
Spart/million, if it increases then it will lead to formation of grooves & pits
in unusual placesas flour is a cytotoxic material.
2- Malnutrition for long periods.
3- Childhoodillness with high temperature for very long period.
% Genetic:
For example amelogenesis imperfect which means imperfect enamel
formation.
- Hypoplasia: it’s caused by incomplete enamel formation whichresult in pits
and grooves morethan normal.
One ofits types is mottled enamel formed due tofluorosis.
 As seen in thepic the
flour causespits &
groovesin the labial
surface where shouldn’t
befound.

Liner enamelhypoplasia
(called lineras it causes
defects ina line pattern
on morethan onetooth),
this pattern is caused by
childhoodillness with
high temperature. In the
picit’s caused by measles.

- Hypomineralization: someparts whiter than the surrounding (white spot) >

in these spots the enamel percentageis less than 96%.

Thepic resemblesothertype of
defects unmentionedin the
lecture.
Tetracycline is an antibiotic;if
takenby a pregnant womanor by
lactating motherthis will affect
the baby’s developing enamel by
participatingin the enamel
composition which causes the
staining appearance.
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 Enamel S
2) Dental caries
- Bacteria that causescaries eat carbohydrates, especially sugar ; then they
produce acids.
- Acids produced by plaque (bacteria pool) dissolve enamel mineral thus
resulting in caries.
- When the mineral is lost, the loss begins at the periphery of the prism as the
organic material is higher there, while in the core the crystals are parallel so
there are less amountof organic material.
- Remineralization could occur in the beginning ofcarries formation (if the
patient brusheshis teeth constantly & decreases the carbohydratesintake),
BUTif demineralization dominates(after cavity formation), the caries
progress.
- Early lesions treatment by tipping the balance towards remineralization.

Dental caries
*The colordiffers
according tothe stain

Erosion
It’s caused by
drinking acidic
drinks a lotlike
orange & lemon
juice.

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 Acidic dissolution
The casein the picsis
called anorexia
nervosa, it’s caused by
a disease where people
vomit there food trying
not to gain weigh; this
food is coming from the
stomach mixed with
acids which causes
teeth dissolution.

Clinical consideration
Restorative dentistry
- Cavity preparation should take the prism orientation in consideration.
Unsupported prisms (which is the enamel not supported with dentine) will
collapse under masticatory forces leading to failure of the restoration. (The
collapse happens because enamelis brittle as we said before and it will break
downforming a new cavity suitable for secondary caries formation)
- Adhesives that bond to enamel are based on understanding the prismatic
structure and the effect of acids on it. (before putting a restoration some acid
is applied on the cavity this acidwill dissolve the prism’s peripheries only as
thecoreis resistant to it whichwill result in rough surface)
- Different acids with different concentrations can producea variety of
patterns ofpartial prism dissolution to provide a rough surface suitablefor
adhering to restorative materials (acid conditioning).
- For agents to mechanically bind to enamel, microporosities are formed on
the surface by acid-etching techniques.

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 - When bondingagents are applied, microscopic tags can be seen invaginating
the roughsurface.

Wear Tooth versusRestoration

COMPOSITE

Abrasive slurry preferentially abrades

AMALGAM
softer polymer matrix — enamel stands
Wearresistance proudof composite. (Here the
dueto ductility — opposite will happen and composite
stands proud of will look lower).
surrounding
enamel. (so
amalgam wears
less than the tooth
structure so after a
while amalgam will
look higher)

Enamelpearls
- Small droplet of enamel on the root, near the furcation. Roots originally
should notcontain enamel, but becauseof errors during development
enamel pearls form.
- It’s formed due to Budding of Hertwig’s root Sheath, when the cells of the
sheath differentiate to form ameloblasts which will deposit enamel in shape
of droplets.

2a| Page
End of the chapter
 Dentine u
Dentine
The outline:

1) Physical properties.
2) Chemical composition.
3) Dentine tubules.
4) Intratubular dentine.
5) Dentinal tubules contents.
6) Regional variations in dentine: mantle dentine, interglobular dentine,
granular layer, hyaline layer, circumpulpal dentine, predentine.
7) Structural lines in dentine.
8) Age related and post-eruptive changes: Secondary,tertiary and sclerotic
dentine and dead tracts
9) Clinical considerations.

Dentine :
1- Formsthe bulk of the tooth.
2- Is formed by large number ofparallel tubules in a mineralized collagen
matrix.
3- The tubules contain the processes of odontoblasts. These processes don’t
extend the entire length of the tubules; (the closer we areto the pulp the
morelikely to find these process, but if we go further near the dentinoenamel
junction the chancetofind themisless).
 4- Asensitive tissue. Unlike enamel; (for exampleif caries is in enamel only we
won'tfeel pain but if reached dentine the acids secreted by caries will move
through the tubulesand reachpulp so wewill feel pain).
5- Formed throughoutlife. So unlike enamel there is always newdentine is
forming, so dentine’s thicknessis increasing at expense of the dental pulp, so
the pulpal tissue decreases with aging.

Physical properties
- Fresh dentine is pale yellow.
- Harder than bone and cementum. Softer than enamel. So the sequence of
hardnessis:
Enamel > dentine > cementum > bone
- Its tubular nature rendersit strong (high compressive,tensile and flexural
strength).
- Permeable, depending on the patency ofthe tubules (decreases with ageing).
The reason behind this is that the lumen ofthe tubules decreases due to
formation ofintratubular dentine.

Chemical composition
Dentine is composed of 70% inorganic component, 20% organic component and
10% water by weight.

Inorganic composition:

Calcium hydroxyapatite Ca1o(PO4)g(OH)2.

The crystals are calcium poor and carbonaterich (due to substitution as

mentioned before in enamel chapter). Much smaller than enamel hydroxyapatite.
The crystals are found on and between collagen fibrils.

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Organi ition:

Collagen (mainly type I) forms 90% of the organic component. Dentine phospho-
proteins, proteoglycans and other proteins arealso present.

Hydroxyapatite

en oe
The Organic Matrix:
- Over 90% of the organic matrix is made ofcollagen fibrils, mainly collagen
type|.
- The componentsof the matrix are:
1- Phosphophoryn (PP-H) properties:
The main phosphoprotein in dentine.
The most acidic protein known.
Due toits high calcium ion binding properties, it has been implicated in
mineralization. (This protein is negatively charged whichattract the positively
chargedcalcium).
2- The main proteoglycansin dentin are biglycan and decorin.
(Proteoglycans = glycosaminoglycan + protein)
Proteoglycans have an importantrole in:
1) Collagen assembly,2) cell adhesion,3) migration, 4) differentiation and
5) Proliferation. 6) They may also havea role in mineralization.

2B| Page
 3- The main glycosaminoglycans are chondroitin-4- and
chondroitin-6-sulphate.
4- y-Carboxyglutamate-containing proteins(Gla proteins):
-Small proteins present in low amountsin dentine.
-They bind strongly but reversibly to hydroxyapatite crystals and may
have arole in mineralisation.

5- Other acidic proteins such as osteonectin, osteopontin are also presentin

dentine. Their function is not known. (But as they are acidic this means
they maybehaverole in mineralization).
6- Some growthfactorsare present in dentine such as insulin-like growth
factor and transforming growth factor. They are absorbed from circulating
tissue fluid. (Absorbed meansthey are not producedby odontoblasts).
7- Lipids comprise 2% ofthe organic content in dentine.
Phospholipids maybeinvolvedin the formation and growth ofapatite
crystals.

Dentine tubules
Dentinal tubules extend from the pulp surface
to the amelo-dentinal junction (in the crown)
and the cemento-dentinal junction (in the
root).
The tubulesare vertical straight up the pulpal
surface & horizontal straight below enamel.
Between them the Tubulesfollow a curved
sigmoid course.
The S shaped tubules is divided into two
curvatures primary (below the enamel) &
secondary (abovethe pulp). The curvature
shownin the pic is primary curvatures.
 - The tubulesarecircular in cross section.
- Dentine betweentubulesis called_
intertubular dentine. And the dentine in 5 eg?
the tubulesis called intratubular dentine. @ ®
In the pic: s® @.@ e .
A> dentinal tubules. \ ae
B > intertubular dentine. .e@ e & ® eo
C > intratubular dentine.
The dark spotinside tubulesis
odontoblastic processes.
r @
008560
Oa) “a e& e Ge,

- The tubules are 2.5m in diameter at the pulpal end and 11m or less at the
Enamelend. (The tubules are not cylindrical in shape so their diameter isnot
fixed along the tube).
- As the odontoblasts retreat inwards, they occupy a smaller area, thus the
tubules becomecloser to eachother.

- During the formation of dentine tubules by the odontoblasts the cells

migrate inwards and occupy a smaller surface area. Hence, the tubules are
more widely separated at their peripheries. Approximately 22% of the cross-
sectional area of the dentine near the pulp is composedof tubules, while
near the enamel—dentine junction the tubules comprise only about 2.5%.

30| Page
 - Secondary curvatures,if they
coincide in adjacent tubules they
give rise to contour lines of Owen.
(Primary dentine is formed before
root completion then; as
secondary curvature starts to form
there will be a sudden change in
the orientation which create the
contourline of Owen, sometimes
there is morethan oneline as the tubules change its orientation but these
lines are not the main one).

- Dentinal tubules branch near the enamel-dentine junction. (This layer of

dentine is called manteldentine).
- Inthe root, the terminal tubule branches and these branchesloop. (This
looping is thought by some tobe responsible for the appearanceof the
granularlayer of Tomes)
- Moreobvious in predentine.

- The walls of newly formed dentinal tubules at the pulp surface are made of
mineralized type| collagen.
- Maturation of the tubules is associated with the deposition of another type
of dentine on the walls. This causes reduction in the size of the lumen,
sometimes completeobliteration. This is called peritubular or intratubular_
dentine.

Bi [Page
Peritubular (Intratubular) Dentine
- Intratubular dentine lacks a collagen a ~@
matrix. Eo ®&
- 15% more mineralised than @ ® 1
intertubular dentine which Increases , ® @ a e .
radiographic and electron density. ; cI i)
- The main proteinin intratubular 8e o& ® eo
dentineis different from L ae (oe j
phosphophoryn.
The inorganic componentis mainly carbonated apatite with a different
crystalline form. (the carbonateis found due to substitution)
Although it is more mineralized we can find some hypocalcified areas.

Physiologic ageing in dentine leads to complete

obliteration of the tubules with intratubular dentine. (it
happens gradually; so the percentageof translucency
increases with timeuntil the obliteration occur and we
can see throughthe root).
Whentheobliteration occur the intratubular dentine
will have samerefractive index as intertubular dentine.
These areas appear translucent when put in water.

32| Page
 - Translucent dentine has a butterfly shapein cross
section. (The bodyofthe butterfly is the pulp while the
translucent dentine represent the wings).
- The wing shapeis due to the convergence of the
tubules.
- Increases with age.
- This phenomenon is beneficial in Forensic dentistry to
identify the age of a person.

Contentsof the dentinal tubules

If we are close to the pulp the contentsare:
1- Odontoblastic processes.
2- Afferent (sensory) nerveterminals.
3- Antigen presenting cells processes.
4- Extracellular dentinal fluid.
But if we arecloser to the enamel or cementum wewill only find
Extracellular dentinal fluid.

1-Odontoblastic processes:
- Variable structure at variouslevels in the tissue.
- Moreorganelles in the predentine area.
- Microtubules and intermediatefilaments.
- Inthe inner layers of dentine, the processes
occupy almostthe full width.
- Sometimes remnantsof the processes (tubulin
and microfilaments) can be seen in the
peripheral parts of the tubules after the process
itself has degenerated.
33| Page
 - 3 hypothesesfor the withdrawal of odontoblasts:
1) The process growsin length as dentineis | L
deposited and its peripheral termination remains
at the outer endof the tubule. Butthis can’t be
right as if we take a cross section in the tubules
from the top (near enamel or cementum) we bse
won't find the odontoblastic process.

|
2) the process reaches a predetermined length and a
then movespulpally as dentine is formed, leaving !
behind an emptytubule in which peritubular
dentine forms.

3) Degeneration of the peripheral end. | | \f

The peripheral end of the processes degrades 5
sequentially and its remains form part of the matrix _
for the peritubular (intratubular) dentine. This L
theory is the accepted one as the scientists
found some odontoblastic processes remnantsin
the tubules awayfrom thepulp.

34| Page
 2- Afferent (sensory) nerve terminals:
- Mainly present in the inner layers of the dentine. (Near the
pulp).
- They haveIntimate relation with the odontoblastic process.
- The axons contain mitochondria andvesicles.
- Their extent in the tubulesis notcertain.
- Incoronal dentine beneath the cusps(in 80% of tubules).
- Sparsein cervical and rootdentine.
- Narrower than odontoblastic process.
- Microtubules, microfilaments. }

3-Antigen presenting cells processes:

- They appear as small processes in the tubulesnear the pulp.
- Thesecells are Immunocompetentantigen presenting cells. (So their function
is to present the foreign antigens to the lymphocytes so the immune reaction
starts).
- The cells are within and beneath odontoblasts.
- Processes limited to the predentine.
- Extend deeper in the tubules under carious dentine.

4-Extracellular dentinalfluids:
- Unknown composition.
- Higher potassium and lower sodium ions level in comparison to other fluids.
This balance affects the membrane properties ofcells.
- Positive force from pulpal tissue pressure. (this pressure is exerted
outwards).

35| Page
Regional Variations in Dentine Structure and
Composition

1-Mantle dentine
- The mostperipheral (first to be formed) layer of dentine. This layer is found
in the crown near the dentine-enamel junction, while in the rootthe first
layer is called Toms granular layer the rest of dentine in both crown & rootis
called circumpulpal dentine.
- 20-150umin width
- Mantel dentine differs from circumpulpal dentine:
1) 5% less mineralized.
2) Collagen fibres perpendicular on the Amelo-dentinal junction. (And the
fibers are parallel to each other).

a‘
3) Branching of tubules.
4) Different mineralization process.

Ea
One i —Reparative
py

Seebndary Circumpulpal
dentin dentin
Conta©2003,Mosby ne Aight sere
 2-Circumpulpal dentine
- Forms the bulk of the dentine.
- Uniform in structure except at peripheries.

3-Interglobular dentine
These regions are formed due tofailure of mineralization process in the
circumpulpal dentine. This process starts with calcospheres (centers of
mineralization which lookslike spheres) which attract minerals and
gradually increase in size; when theyreach the critical size they fuse
together to form homogenous matrix of mineralized dentine. BUTif these
spheresdidn’t reach the critical size they won’t fuse and this will leave an
empty organic spaces between the spheres; and this explains why they
call it inter-globular dentine.
- It can be found in any region in the circumpulpal dentine but usuallyit’s
found beneath the mantel dentine.
- Inground section the organic matrixis lost; so they appear as dark areas
under the light microscope. (as shown below)
- Tubulespass through theseareas.

37| Page
 4- Granular layer of Toms
- Peripheral root dentine has a dark granular zone.
- It’s formed becauseof Dentinal tubules branching and looping back on
themselves which createsair spaces. This gives Tree top appearance of
tubules.
- They are a Hypomineralized granular layer.
- Other explanation is incomplete fusion of calcospherites; butit’s not well
established.

5-Hyaline layer
- It’s found outside the granular layer of toms. And it has an obscureorigin.
- Up to 20umin width.
- Atubular and structure-less; so it’s a homogenous layer.

38 | Page
 6-Predentine
- It’s an initially laid dentine matrix prior to mineralization.
- Between the predentine & dentine thereis an interval called Intermediate
dentine OR mineralization front ORcalcification front. The Mineralization
front may show globular or a linear appearance whichrepresent the
calcospheres.
- 10-40um in width thicker in young teeth.

Structural lines in dentine

- Lines associated with the primary curvatures of dentinal tubules (Schreger.
lines). It’s formed due to the coincidence of the primary curvature
- Lines associated with the secondary curvatures ofdentinal tubules (Contour
of

- Incremental lines:
Von Ebner’s lines (Daily resting lines)
Andresen lines (Weekly resting lines)

39| Page
 1-Schregerlines:
- Peaks of sigmoid primary curvatures coincide.
- Can be ONLYseen in Ground Longitudinal sections
at magnification. (Difficult to see in cross
sections).
- Ainthe pic representsit.

2- Contour line of Owen

- The main (Exaggerated) line is a border of primary & secondary curvatures.
While the minor ones forms due
to Coincidence of secondary
curvatures.

- Inthe pic there is a prominent

black line (one of the weekly
incremental lines), if found in
deciduous teeth or permanent
first molar then called Neonatal
line. Other than thatit’s called Owenline.

3-Incremental lines
- Short and long period markings.
- Fluctuationsin acid-base balance.
- Effect on mineral content, thusthe refractive index.
- Change in collagen fibres orientation.
- Short term striations (von Ebner’s lines).
> In Cuspal dentine: 4m separate every 2 lines.
> In Root dentine: 24m separate every lines.
40 | Page
 v So the amountofdentine produced daily in cuspal dentine is more than
root dentine.
> Theselines run perpendicular to the tubules. They can be seen only
with very high magnification.

- Long term striations (Andresen lines).

> 16-20um apart. > Exaggerated
> 6-10lines of Von Ebner’s neonatalline.
between every 2.

41| Page
Age Related and Post Eruptive Changes
= Dentine can undergoseveral changes thatareeither related to
1) Physiological age changes:
a- Secondary dentine (after root formation).
b- Translucent dentine (in the root dueto the obliteration of dentinal tubules by
intratubular dentine).
v Those are NOTpathological conditions just physiological conditions
related to age.
2) Changesassociated with dentinal responsesto stimuli:
a- Tertiary dentine.
b- Sclerotic dentine.
c- DeadtractsofFish.
v Examplesofstimuli: caries & attrition.

1) Physiological age changes:

a- Secondary dentine:
Secondary dentine starts to form oncethe rootis completed and the tooth
comesinto occlusion.
(These twosituations occurred at the same time, the completion of root
formation occurred at same time whenthe tooth comesinto occlusion with
the correspondingtooth).
Very similar to primary dentine.
Sudden changein the tubules direction.
Slower deposition (than primary dentine)
Closer incremental lines in secondary dentine in comparison with the primary
dentine.

42 | Page
 > You can see here a sudden changein the tubules direction

Contour line of
4° Dentin Owen

Cat eae un

b- Translucent Dentine:
- Obliteration of tubules with intratubular dentine.
- Root dentine.

2) Chan if with dentinal ri

to stimuli:
a- Tertiary Dentine:
- It has two types:
> Reactionary dentine formed by odontoblasts.
> Reparative dentine formed by odontoblast-like cells, which are
differentiated from stem cells in the pulp.

43 | Page
 - External stimuli might induce the pulp to produce morecalcified material.
** This responsetissue has beengiven a variety of names, including:
- Other namesfor tertiary dentine: irregular secondary dentine, reparative
dentine, reactionary dentine, response dentine and osteodentine.
- Variable appearance and composition.
So it may be tubular, may contain few irregular tubules, maybe atubular.

Inclusion

‘Natural odontoblast(tall)

Reparative tertiary dentine

Odontoblast-likecells (short) shaped cuboidal
orflat
The cells that formed the tertiary dentine
afterdifferentiationof the stem cells of the
pulp.

4a| Page
 Irregular tubules; so it’s a
tertiary dentine

Short cells (flat or cuboidal).

- Stimuli inducecells in the pulp to differentiate into “odnontoblasts”.

(reparative)
- Primary odontoblasts mightbe involved in the early stages. (primary
odontoblast producedreactionary, but odontoblast-like cellsproduced
reparative).
- Production of collagen type | and dentine sialoprotein.
- Epithelial mesenchymal interaction. >message similar to the original
epithelial mesenchymal interaction).
- Dormantcells are stem cells whichis induced to differentiate to odontoblast-
like cells to produce reparativetertiary dentine.
- Factors released during inflammation > will induce stem cells to
differentiate to odontoblast-like cells to form the reparative dentine.

45 | Page
 b- Sclerotic Dentine:
- Stimuli induce the deposition of material inside the tubules and Sclerotic
dentine is the result.
Very similar in appearance to transparent dentine (translucent dentine).
Different composition from intratubular dentine.
Apatite crystals possibly, octacalcium phosphatecrystals.
Exposed tubules might contain occluding components from saliva. (there are
some componentsofsaliva in the sclerotic dentine as a part of materials that
close the tubules).

Sclerotic dentine:

It’s found underfishers (sulcus)or pits

in enamel, it’s formed due to
demineralizationofthethin enamel,
so these minerals go downandblock
the tubules.

c- Dead Tractsof Fish:

- Primary odontoblasts could be killed by external stimuli or they retreat
before the formation ofintratubular dentine; this results in empty tubules.
- Might be sealed at their pulpal end by tertiary dentine.
- Air filled, thus light will be internally reflected, and they will appear dark
under light microscope. Dead tractsare the term given to theseair-filled
tubules.

46 | Page
 here we have dental carries caused by bacteria; which producesacids that move
forward toward the tubules according to how much acid we have,if it was little
amount then the odontoblasts will produce reactionary dentine (regular
tubular). But if the acid killed the odontoblasts; then odontoblast-like cells will
appear and producereparative dentine. So in both situations the tubules will be
blocked on the pulp side.

So the tubules here are blocked even with

/ reparative or reactionary dentine (sclerotic
_ dentine); so the acid will move back & forth
in the tubulesuntil the intratubular dentine
is dissolved. So the tubules lumen looks
morewide,air filled & dark in ground
section.

end of the chapter

47 | Page
 Dental Pulp E
Outline
1- General organization ofthe pulp.
2- Composition: Fibres, non-fibrous matrix,cells.
3- Bloodvessels.
4- Nerve supply.
5- Regions ofthe pulp.
6- Age related changes.
7- Clinical considerations.

1-General organization of the pulp

= The pulp is contained within the pulp chamber and the
rootcanals.
pulp in the crown is called > pulp chamber
While in the root > pulp canal

- Apically, the pulp becomescontinuous with the periodontal ligament.

(At the end of root canal, the pulp across the periodontal ligament (which is a
Soft tissue around the tooth)).

4B | Page
 Dental Pulp p

- The pulp is specialized connective tissue. Dentin

= Structures wecan seeit in the pulp:
1- Odontoblastslie on the peripheries.
(odontoblastslie under the predentine- itis
considered to be as a partof the pulp)
2- Nerve terminals.
3- Antigen presenting cells.
4- Bloodvessels.
5- Eachroothasat least one canal. (One or two
canals).
6- Accessory canals apical third. (collateral or lateral root canals)
v These canals cause some complications in root canal treatment, as some
timesafter the dentist has done a
perfect work with the RCT the patient Boreal Crown
still feels pain due to the inflammation
or some deadtissuesthatexist in the a
accessory canals. o
Pulp
Chamber
Root Cena! Root
Pulp Tissue
il if

49| Page
7 Dental Pulp

2-Composition: Fibres, non-fibrous matrix, cells.

= Cells in an extracellular matrix. (we have 2 typesof extracellular matrix:
Fibrous (most ofit is collagen), and non- fibrous.)
= The pulp of composed of:
- 75% water by weight.
- 25% organic material which includes: polysaccharides, proteins.
- Fibres, non-fibrous matrix.
- Collagen is the main component offibers.

Fibres: (they are arranged accordingto their

1) Collagen
a- Collagentype I:( most abundant)
Fibrils thinly scattered through the pulp.
Randomly organized (exceptat peripheries).
At the peripheries, they are parallel to the predentine surface.
Right angles to the amelo-dentine junction in mantle dentine (von Korff’s).
(anything located in dentine wasoriginally made bythe pulp, after that
dentine has been formed, because wesaid before that the odontoblasts are
part of the pulp...Ex: The Mantle Dentine originally was pulp then itbecomes
dentine, and thefibres inside it come from the pulp , these fibres are parallel
to eachotherand at right angle to the dentino- enamel junction, it has a
special name: Von Korff’s fibres).

50| Page
 Dental Pulp S

The pic showsthe collagen which is

a triple helix which makes > the
micro fibrins which makes > the
fibrils which makes > thefibers.

b- Collagen typeIII :( the second most abundant)

- Present in large amounts. (less than type 1)
- Similar banding pattern as type |.
- Has only a1 chains (**a1 and a2in type 1)
- 41% ofpulpal collagen. (/ess than half of total pulpal collagen, while collagen
type1 take morethan the half).
c- Collagen typeV:present in small amounts.
d- Collagen type VI: present in small amounts.

2) Eib :
- Microfibrils smaller in diameter than collagen (so microfibrils offibrillinare
smaller in diameter than microfibrils of collagen).
- Large glycoprotein (but less than collagen).

51] Page
7 Dental Pulp

“ Non-Fibrous Matrix:
Glycosaminoglycans, Proteoglycans and Other adhesion molecules.

1) Glycosaminoglycans:
- Polysaccharide chains composed ofrepeating disaccharide units.
- Bulky hydrophilic molecules that form gels. (Glycosaminoglycan is always a
jelly material because theyare attractive to water(highly hydrophilic) sothey
form gels).
types of glycosaminoglycans:
A. Chondroitin sulphate predominates. (the MOST abundant,asin
dentine).
In less amountsthereis:
B. Dermatan sulphate.
C. Heparan sulphate
D. Hyaluronan (found unbound toproteins) special feature forhyaluronan,
unlike other type, they are boundedto proteins within a structurecalled
(proteoglycan).

9
0=$-0

Proteoglycan complex

As showninthe picture the Hyaluronan could be

bounded(in proteoglycan complex) or unbounded.
52] Page
 Dental Pulp p
2) Proteoglycans:
- Core protein surrounded by
glycosaminoglycans.
- 5 types of proteoglycans in pulp:
1- Decorin: bind collagen and TGF-B NH
(transforming growth factor beta). GAG—Les)—(Gn)Oo 5 an
trisaccharide link
2- Biglycan: regulatescollagen fibrinogenesis.
3-Versican: forms proteoglycan aggregates.
4- Syndecan: attachescell surface to collagen.
5- Tensascin: cell adhesion molecules which guides cell movement.
**Fibronectin and Laminin are non-fibrous (adhesion molecules).

3) adhesion molecules:
» Fibronectin:
- Glycoprotien.
Cell attachment to extracellular matrix.
Attachmentto the cytoskeleton, thus regulating cell shape, migration and
differentiation.
Widely distributed in the pulp.
Cell adhesion molecules that bind with integrins.

> Laminin:
- Another cell adhesion molecule which interacts with integrin.
Forms part of basement membranesand binds epithelial cells to extracellular
matrix (where ever wefind epithelialcells there is a laminin surrounding
them).
Binds signalling molecules.
Presentin pulp only around endothelial and Schwann cells. (the endothelial
cells are originally epithelial cells, and the Schwann cells are nervous tissue
whichis derived from Ectoderm)
Odontoblastic bodies and processesare coated with laminin.
53] Page
7 Dental Pulp
“Cells in the Dental Pulp
- Odontoblasts.
- Fibroblast (everywherein the pulp)
- Immune cells (also everywherein the pulp)
- Undifferentiated cells (everywhere BUT MOSTofthem arelocated in the cell-
rich zone). ce b .

1) Odontoblasts:
- fully differentiated odontoblastis a polarized columnar
cell with a long processinside a tubule (polarized= the
nucleusnot at the middle)
- Cell body: 50pm long and 5-10um in width.
- Small processeslink adjacent odontoblasts and other
pulp cells.
- Odontoblasts form a layer ofsingle cells
attached to the predentine by a single
process.
- Coronal odontoblasts are columnar in
outline, while they are almost cuboidal
in the root. (So the odontoblasts in the
crown are taller than the ones in the
root).
- In oblique sections, they appear pseudo-stratified.

- Types ofcell junctions between the odontoblasts:

a- Desmosomes: mechanical union
(By intermediatefilaments)
Their role is only mechanical as they aren’t found in the peripheries.

54] Page
 Dental Pulp S
b- junctions:limit
Tight permeability, mechanical integrity.
(it’s like a door as they allow materials to pass or not)
oocludens Zonula
Zonula adherens ~actin filaments.

c- junction: synchronization (chemical channels > for chemical

messages exchanging between adjacent cells which is a role in
synchronizing the activity ofall the odontoblasts).

2) Fibroblasts:
- Scatteredall around the pulp.
- Variable morphology (different shapes)
- Theyslowly producefibres and ground
substance.
- Pulp fibroblasts can degrade extracellular
matrix (they have opposite om x
functions: produce and degrade extracellular = 5 =
matrix). This process is to keep the tissue Weer a, Bes
renewedand it is called Matrix turnover.
- When properly stimulated in vitro they can Se 7 .
produce hard tissue
55| Page
7 Dental Pulp

(fibroblasts are not fully differentiated; theycan

differentiate furthermore; undercertain
situationsthe fibroblasts can produce a
calcified tissue like dentine or bone or
whatever...)
- Production of growth factors and cytokines.
- Fibroblasts die by process called APOPTOSIS
“programmedcell death” > make
degradation byitself.

3) ImmuneCels:
All the immune cells are found in the dental pulp but these are the most
abundantones:
- T-lymphocytes “Re
- Macrophages re)
- Dendritic antigen presenting cells

a- T Lymphocytes:
- Small numbersin normal pulp.
- Numbers increase when the pulp is injured.
- Incase of inflammation or injury in the pulp, T-
lymphocytesincrease in numbers.

- In T-lymphocytes, the nucleus occupies mostof its volume and the amount of
cytoplasm is very small).
“HIGH NUCLEAR TO CYTOPLASMIC RATIO”

56 | Page
 Dental Pulp S

b- Macrophages:
The nucleus is Kidney shape, more cytoplasm, larger
than T lymphocytes.
- Different morphologies in resting form.
- Widely distributed in the pulp.
- Available in big numbers.
- Denser around bloodvessels and odontoblasts.

c- Dendritic Antigen Presenting Cells:

- 50m long (large cells, even larger than Macrophages).
- Three or more branching processes.
- More numerous around blood vessels and odontoblasts (like Macrophages).
- Antigen presenting cells, induce T lymphocyteproliferation. (the cells
associated with external antigen > send signals that stimulate the division
and activity of T lymphocytes)
- Might migrate to regional lymph nodes(these cells can move from the pulp
and reach to near lymph nodes).

When the dendritic cell is

ce Caer
associated with an antigen — it
induces T cells to cause immune
response against the foreign
antigen.
Menta

57| Page
7 Dental Pulp

4) Undifferentiated Cells
(Stem cells, most abundant in cell-rich zone).
- Anumber ofcells beneath the odontoblastic layer capable ofdifferentiating
into odontoblasts.
- Pluripotent primitive mesenchymal cells that could differentiate into a
variety of cell types (it can differentiate to any type ofcells according to the
signals it receives, whichdirectsit to differentiate to a specific kind ofcells).
- Modifying cell activity by a change in gene expression.
- some people consider it as Modified Fibroblastbutit’s still a suggestion.

3-Blood vessels
- Closerelation with the nerves(especially the arterioles > the
closest to the nerve bundle).
- Arterioles and venules enter the pulp via the apical foramen and
lateral canals.
- Larger vessels are 150m in diameter.
- They run inside the root canals giving branches to the
peripheries. (But these branchesare few in root, the main
branching occursin crownascapillaries, then these capillaries
are connectedwith eachotherforming venules).
Arterioles > the blood enterthe tooth.
Venules > the blood goesoutside the tooth.
- Profuse branching oncewithin the coronal pulp chamber.This branching
forms Subodontoblastic which is found in cell-rich zone.
- Capillaries are 6-8m in diameter.
- Within and beneath odontoblasts(not just at cell-rich zone, but even within
and beneath odontoblasts).

58| Page
 Dental Pulp S
- 4-5% are fenestrated with only a basement membrane at their wall
(fenestrations 60-80nm in diameter).
- (the function of blood vessel fenestrations is to facilitate an easy exchanging
between capillaries and the surrounding environment).

- Arterio-venous and yenous-venousanastomoses.(grterio-venous means

connection betweenartery and vein without branching to a capillary, and
same for venous-venous anastomoses between twoveins).
- Wealsocan find Lymph vessels in the pulp.
- Vasoconstrictor nerve endingsin association with arteriole’s smooth muscles
(control the diameter of the blood vessels > the blood flow)
If the vessel is Constricted > low blood flow
If it is Relaxed > high blood flow

- Pulpal blood flow 2-60 ml/minute per 100goftissue; which is considered

“high fluid pressure” in the pulp.

Odontoblasts —iy N
sgl
Cell free zone |
Cell rich zone

P.S: don’t worry about it, the

pics in the exam will be
clearer and the zones are
easier to distinguish.

59] Page
7 Dental Pulp

4- Nervefibers
- Asan example: 2500 axons (nerve fibres) enter a mature premolar.
- 25% myelinated afferents with sheath (so,75% is unmyelinated).
- 90% (of the 25% myelinated) of which are_Aé fibres which are 1-64m in
diameter.
- A&are thin myelinated axons with a moderate conduction velocity.
Associated with acute pain and with sensations of temperature and pressure
(so by myelinated axonsthe transmission of nerve impulseis faster).
- The remainder of myelinated nerves (10%) are_AB fibres (6-12,m in
diameter). Afferent fibres that carry non-noxious sensations.
(carry other sensations but notsensations ofpain, like temperature, pressure
or chemical sensation).

- Unmyelinated C fibres (75%) are the majority of nervefibres in the pulp.

- It has two types: Afferent (sensory) or autonomic (the autonomicis
sympatheticfibres associated with blood vessels) > which controlthe
diameter of the blood vessels.
Note: AutonomicNS is 2 types: sympathetic & parasympathetic, here in the
pulp we have only sympathetic type.
- Cfibres have a slow conduction velocity. Associated with chronic or dull pain
(like gum inflammation), and with sensations of warmth, as well as
mechanical and chemical stimuli.
v So the non-noxious sensation is carried by different fibers including Aé and
AB and C fibers. But:
Acute pain > only carried by A6.
Chronic or dull pain (or called discomfort feeling) > only carried by C fibers.
- It is thought that mostfibres are Nociceptors (most offibres in the pulpcan
transfer “pain” such as Aé and C fibres).
 Dental Pulp S

= Nerves
- Nerves enter the pulp as part of the neuro-vascular bundle > they moveside
by side with Arterioles, from wherethe arterioles get in the tooth, the nerve
bundles also get in from the same place (from apical foramen or lateral
canals).
- They branch in the coronal part of the pulp. (there is some branching inthe
root but It’s not that much and the main branching is in the crown).
- Branchesend in and around the odontoblastic layer. (Branches can pass
through the odontoblasts and in subodontoblastic region, and some fibers
enter the tubulesfor short distance(especially in predentine)).
- Aplexus of nerves beneath the odontoblasts (Plexus of Raschkow). (main
dividing of nerves happensin crown, giving a plexus called Racshkownerve
plexus locatedin cell rich zone).
- The plexus is evident after tooth eruption.
- This pic represents raschkow nerve
odontoblasts
plexus.
Vv Fibres pass through supraodontoblastic
| Predentin
region are called Bradlaw nerve plexus.
v Why the cell-free zone lookslike it has
cells in it? because the stain used is
specialized for nerves,so it highlights the
nervespasses this zone. (In pulp core
there are nerve bundles)

- Branchesfrom the plexus enter the dentinal tubules. (nerve plexus gives
branchespass through cell-free zone > odontoblasts > supraodontoblastic
zone > enter the tubulesfor shortdistance).

61] Page
 - Manyaxons in the tubules,at the peripheries of dentine and among
odontoblastic bodies are devoid of Schwann cells. (which means manyofthe
axonsthat enter the tubulesor exist within odontoblasts are unmyelinated;
as schwancells is responsible offorming it).

- Asit is unmyelinated this facilitates their response to stimuli from the

immediate environment.

- Neuropeptides, mainly calcitonin gene-related peptide (CGRP) is produced by

the (sensory)nervefibres.

- CGRP is a vasodilator.soit controls the pulpal blood flow.

- Synthesized by neurons and transported by axons (neuropeptides are

synthesizedin the cell body of the nerve whichexist in the central nervous
system, neuropeptidesare transported along the axon and theyare secreted
from nerve terminals).

- May contribute to the control of hard tissue formation (like dentine).

- Main function of nervesin the pulp is maintaining the local environment.

(due to the controlling of the bloodflow. In case of inflammation > secretion
of neuropeptides increase > causing vasodilatation >increase blood flow so
wefeel pain dueto theincrease of pressurein the pulp chamber).

62| Page
 Dental Pulp S

5-regions in dental pulp

1- Supraodontoblastic region. (between
odontoblasts and predentine)
2- Odontoblastic layer.
3- Subodontoblastic region which contain:
-Cell- free zone of Weil.
-Cell-rich zone.
4- Bulk of the pulp.

> Supraodontoblastic region

- Itis between the odontoblastic cell bodies and
the predentine.
- They appear due to tissue shrinkage. (Soin reality it doesn’t exist, ‘but wesee
it in the histological section due to shrinkageoftissues during preparation).
- Inthis layer Unsheathed axons (unmyelinated sensory nerve terminals) are
present, together wecall them predentinal plexus of Bradlaw.
- Also processes of Dendritic antigen presenting cells are present.
- This the first region in the pulp where changes in the tubules could be
detected.

> Cell free zone of Weil

- Cell free zone. (it’s called so because there are not anycell nuclei in
this region).
- Cell processes offibroblasts and antigen-presentingcells, axons and
capillaries cross this region.
- Anuclear zone is a better description. (As it has somecellular parts but
doesn’thave any nuclei).
- Only in the coronal pulp of erupted teeth.

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7 Dental Pulp
- Insome referencesit’s said to be an Artefact, so not present in reality butit’s
a result of tissue shrinkage.

> Cell rich zone

- It’s also said to be an Artefact, so resulting of tissue shrinkage.
- This layer contains :
1- Subodontoblastic capillary plexus.
2- Subodontoblastic neural plexus, which is called Raschkowplexus.
- Cells associated with these plexi could result in the richnessof this zone.

> Bulk of the pulp

- It is the central area of the
pulp.
- Loose connectivetissue.
- Itis rich with blood and
nerve supply.

Regionsof
the dental
pulp

64| Page
 Dental Pulp p

6-Aging of the pulp

- The pulpal size decreases with age. As the secondary dentineformation
continues throughout life at expenseof the pulp.
- Decreased vascularity.
- Morefibrous.
- Reduced innervation.
- Decreased cellularity.
- Calcification appears as:
1- Pulp stones. (true or false)
2- Small specs, snow storm calcification.

> Pulp stones(denticles):

- Single or in groups.
- True denticles resemble dentine (tubular). (so they
Havetubuleslike dentine)
- False denticles resemble bone (so they have
trapped cells). They are Lamellated stones, having
concentric lamella lookinglike onion.

- Some stones may be attached to dentine. (Pulp stonesare ether free,

attached or embedded).
- They are asymptomatic and discovered coincidentally. It may cause

re re |
Complication in root canal therapy especially if it is large and attached.

65 | Page
7 Dental Pulp

7-clinical consideration
Systemic and genetic defects in dental tissues are mediated through the
pulp.
The sense organ ofthe tooth, thus requires anesthesia.
Defense against caries, trauma...
Pulp inflammation is painful and difficult to localize.

Exposureoflateral canals to the oral environmentis painful. (this happensin

case of inflammation of the gingival pocket which enablesbacteria to reach
the lateral canals and causepulp inflammation, so the doctor must look after
it if the tooth is symptomaticalthough thereis no caries).

Pulp exposure during cavity preparation. (This happens during removal of

caries; an accidental exposure may happenin this case wecall it “Clean
Exposure”; so no needfor root canal treatment wejust add a material called
calcium hydroxide whichinducesthe formation oftertiary dentine bridge
whichwill save the pulp from inflammation).
Y Note: Pulp inflammation (pulpitis) starts as reversible inflammation
characterized by pain upon stimulation only, such as feeling pain when
drinking cold water which go immediately after finishing. If not treated
it will become irreversible inflammation and the pain will continue
evenif the stimuli is removed, here we mustdo root canal treatment
(RCT) for diseased pulp.

66 | Page
 Dental Pulp S

- After trauma the tooth will undergoan internal or external resorption or

both. External resorption happens to cementum while internal resorption is
for dentine.
In case ofinternal resorption Transformation into granulation tissue
following trauma occur (which is considered chronic painless inflammation),
leading to resorption of dentine by “odontoclasts”. Which finally leads to
Pinkish coloration of the tooth.
In this case we mustdo RCT as this process is continuous and after losingall
dentine the enamel will be left brittle and break down easily.

v Note: always clast means a cell the cause resorption, like osteoclastit
causesresorption of the bone...

67 | Page
 Dental Pulp

Beneficial Summary Charts ©

Typet(most abundant)
jeer <+ type second mostabundant)

Dental pe Fibres hy Fibril Type5,6 (small amounts)

ee (large glycoprotein)
nonfibrous
ntl lpenemlenmnnaed
aProteogtycans oe
Condroition Hyaluronan Dermation
Ng aaa
mie : I yee vane a
Fires = mi al Verwcan Syndecan

Production

Odontoblasts Fibrobla —
Degradation
wt ‘T-Lymphocytes (high nuclear to cytoplasmic ratio,small numbers)

Inna Mpgeisrend
eeeaa eeeeeaae

A 90% Ad (acute pain and other sensations)

Myelinated 25%
Axons 10% AB (non-noxious sensations)
7 Afferent
Unmyelinated 75% (c fibres) —- choronic or dull pain

Autonomic

68| Page
 Cementum
Outline
1- Physical properties.
2- Chemical composition.
3- Classifications of cementum.
4- Attachmentto adjacent structures.
5- Resorption and repair of cementum.
6- Clinical considerations

> The periodontium:

- Represents the tooth supportingtissues in the jaws.
- It comprises: Ff
1- The cementum. (/i’s also considered part of the tooth). 4. f ®
2- The periodontal ligament. (/t’s responsible of tooth AY ' iH
attachment to the alveolar bone). r\ al it
3- The alveolar bone. | i if
4- The gingiva.

> Cementum
- Itis a Thin layer ofcalcified tissue covering radicular dentine.
- Cervically,it is 10-15m in thickness. OS
- Apically,it is 50-200umthick. numbers, youjust
should know whereit’s
ec
69| Pace
 Periodontium 1

Could exceed 600mat rootapex. (thickness Enamel

Dependsonthe age;asit increases with age so we can’t satin
find a young person with 600m thickness).
Pulp
It Adheres to dentine and to the periodontal ligament.
Capable of repair and regeneration. (As the
cementoblasts are found on the surface which allows
them to repair resorption)
Formed throughout life, allowing re-attachmentof the
periodontal ligament. cts tn sin
Thereis alwaysa layer of uncalcified precementum.
Precementum = unmineralized cementum = cementoid
Y Note: This type is obvious in the surface of cellular cementum, while in
the acellular type we can’t see it as the mineralization process occur
fast.
Similar to bone in composition, but notinnervated and avascular. (So for
nutrition it dependson diffusion from the periodontium).

1-Physical properties
Cementum is pale yellow.
It has a dull surface.
Softer than dentine.
Variable permeability. (/t varies depending on the age).
More permeable than dentine. (/t has more percentage of water than
dentine due to the high permeability; as it has more pores).
Easily abraded cervically. (As it is thin in that area, this happensin case of
root exposure; and after abrasion of cementum due to heavy brushing the
patient will feel pain as dentine is exposed whichis a sensitive structure).

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 Periodontium 1

2-Chemical composition
65% inorganic material, 23% organic material and 12% water by weight.

Inorganic component:
Mainly hydroxyapatite, with other calcium forms. Thin plate like apatite
crystals, unlike enamel that looks hexagonal.
Organic component:
Collagen type I, and non-collagenous elements similar to bone; sialoprotein
and osteopntin. Similar to bone components.

3-Classification of cementum
The classification is in three ways:
1- Presence or absence ofcells:
-Cellular cementum
-Acellular cementum
2- Nature and origin of the organic matrix:
-Extrinsic fibre cementum, its origin is from the periodontium.
-Intrinsic fibre cementum, it’s formed by the cementoblasts on the
surface.
-Mixed fibre cementum.
3- A combination of both:
-Acellular extrinsic fibre cementum.
-Cellular intrinsic fibre cementum.
-Mixed fibre cementum (cellular). /f may be cellular or acellular.
-Afibrillar cementum (acellular), this type is seen in case of overlapped
cementoenamel junction where cementum overlaps the enamel.

[Page
 Periodontium 1
1- Presence orabsenceofcells:
Cellular cementum contains cementocytes.
Acellular cementum covers the dentine. This typeis also called intermediate
cementum, which comes immediately after the hyaline layer.
Cellular cementum mainly in the apical area and inter-radicular (furcation)
areas overlying acellular cementum.
Variations in their arrangement. This occur in the med region of the root.
v So the arrangement oflayersin different areas is:
-In cervical area: always acellular.
-In apical & inter-radicular areas: intermediate cementum > cellular
cementum.
-Medregion: alwaysstart with intermediate cementum > then there is
variation it could be cellular or acellular depending on the rate of
production.
- Primary cementum (acellular); primary means the first one to be produced
which is the closest to dentine (intermediate cementum).
v Primary cementum intermediate cementum; which is acellular.
- Secondary cementum is produced after primary, may becellular or acellular
depending on the region.

This pic is an example of the

variation area taken from
the med region, so firstly
closest to the dentine there
is the intermediate layer
(acellular) then cellular then
acellular then cellular.

- Acellular cementum appearsstructureless.

T2| Page
 Periodontium 1

Darkline between hyaline layer and acellular cementum (intermediate

cementum) marking afibrillar cementum. This line is called cementodentinal
junction.
- Differences betweencellular and acellular cementum are due to the
differencesin the formationrate of both tissues.
Y InCellular cementum the amountproducedper time is high which
allows entrapmentofcells so the result in having cells inside.
While in acellular the amount producedper time is low; so there is no
chance for entrapmentwhichresult in this acellular appearance.
- incellular cementum wefind:
1- Lacunae (where cementocytes are found).
2- More widely spaced incremental lines (about year between every 2 lines),
which result from the production of high amount assaid before.
3- A layer of precementum, as the amount produced per time is high the
time needed for mineralization is more which allowsus to see this layer.

- Different relations betweencellular and acellular cementum.

Cementocytes are trapped in lacunae with canaliculi.
Canaliculi oriented towards periodontal ligament.

Tl Page
 Periodontium 1
- Cementocytes areinactive. (The active one always ends with blast,
cementoblast whichis found on the surface).
Some properties of inactive cells “cytes”:
1- Low cytoplasmic/nuclear ratio. (The amount of cytoplasm is low with large
nucleus).
2- Minute amounts of energy and protein synthesizing organelles.

- Cementum is deposited with an irregular rhythm resulting in incremental

lines of Salter. One year separate every2 lines.
- Incremental lines mark differences both in mineralization and in organic
matrix composition. (this is the reason that let us to distinguish the lines).

RCacets

Tal Page
 Periodontium 1 L

2- Origin of the organic matrix:

- Two main sourcesof organic matrix:
a- Extrinsic Fibres:
Derived from Sharpey’sfibres of the periodontal ligament.
Y Note: sharpey’sfibers are collagen fibers inserted in calcified matrix
(including bone or cementum).
b- Intrinsic Fibres:
Derived from Cementoblasts.

- Sharpey’s fibres enter the cementum perpendicular or slightly oblique to the

rootsurface.
- Intrinsic fibres run parallel to the root surface. (so also parallel to the
cementum).
- Mixedfibre cementum contains bothtypes.

TP age
 Periodontium 1
3-Combinationofcell presence and matrix origin includes:
- Acellular extrinsic fibre cementum.
- Cellular intrinsic fibre cementum.
- Cellular mixed fibre cementum.
- Afibrillar cementum.

1- Acellular extrinsic fibre cementum (AEFC):

Vv Note: the extrinsic type is alwaysacellular.
- Mainly over cet half. (Esp. the cervical third, remember the med third
has variation).
- Bulk of cementum in premolars. (So in premolar it extends more than the
cervical half).
- The first formed cementum. (Referring to the intermediate cementum).
- Could reach 15m in thickness.
- All the collagen fibers extrinsic.
- Ground substance may be a product of cementoblasts.
Y So the ALLfibrous part is extrinsic (from the periodontal ligament), but
the non-fibrous is formed(intrinsic) by the cementoblasts.
- Covers cervical twothirds of the root.
- Well mineralized fibres.
- Thin black lines on ground sections due to the loss of unmineralized cores of
the fibres; this is why Sharpye’s fibers appearsdark in color.

Tél Pace
 Periodontium 1

This pic represent a decalcified section of AEFC, which

PereaCaursekeeeees
ENacmLCA
Pe ereeen-caars
Ses oe
lee esteser MareeCUTIgccr
De eeeEne
E > intermediate cementum

2- Cellularintrinsic fibre cementum

- Intrinsic fibres parallel to the root surface.
- No role in tooth attachment to the periodontal ligament; as the fibres don’t
invadeit.
v Important note: this type is found on the surface.
- Apical third of the root and in the interradicular area. But noton the surface
just in the inner layers, as if the top one is cellular it must be mixed.
- If formed slowly, acellular extrinsic fibre cementum could result. (So
changing the rate of formation would change the type).

BCE
etd
ears
read
cis

Cesar)
ee

TI| Page
a Periodontium 1
3- Mixedfibre cementum
- Both extrinsic and intrinsicfibres.
- Different orientation almostat right angles. (as extrinsic fibres comes in 90°
or slightly oblique, and intrinsic are parallel to the cementum;so the angle
between themis almost 90°).
- Different bundle sizes:
= Extrinsic fibres are ovoid or round, about 5-6m in diameter.
= Intrinsic fibres are 1-2um in diameter.
Soextrinsic fibres are about 3-5 timeslarger than intrinsic fibres.
- Acellular mixed fibre cementum forms slowly and is
well mineralized.
- Cellular mixed fibre cementum forms quickly and the
fibres are less mineralized especially at their cores.
v Alwaysthe slowly formed type is well
mineralized unlike the fast formed type.

4- Afibirllar cementum
- No collagen fibres.
- Sparsely distributed.
- Well mineralised ground substance.
- Some saysthatit is Epithelial in origin like hyaline
layer whichis formed bycells called Hertwig’s
epithelial root sheath. (this is thought because these
twolayers are adjacent to each other).
- This typeis found in:
1- Thin, acellular could overlap with enamel.
2- Between fibrillar cementum and dentine.
(Between intermediate cementum & hyaline
layer).

Tal Page
 Periodontium 1 L

Mere
Cemenerean)
Freon
Overlapping cementum
VeeRi)
Piceaalla)

4-Relation with adjacent structures

- Cemento-enamel junction.
- Cemento-dentinal junction.
- Attachment of cementum to the periodontal ligament.

1- Cemento-dentinal junction
- Intermediate layer between the tissues. (between cementum & hyaline).
- AnchorsPeriodontal fibres into dentine.
- Hyaline layer comes immediately after Tom’s granular layer, then we have
the inner most cementumlayer (whichis other namefor intermediate
cementum).
- Avariety of names has been given to the intermediate layer which includes:
Innermost cementumlayer, superficial layer of root dentine, intermediate
cementum, Hyaline layer.

79| Pace
 Periodontium 1

- Tom’s granular layer:

= Itis a wide irregular spaces that may interconnect with tubules.
= Theories that explain the formation ofit:
-The spaces mightbe related to entrappedcells.
-They mightbe enlarged tubular terminals.
And as wesaid the most acceptedis branching & looping back of the
tubules on them self.
- There is Differences between speciesin the appearance of Tom’s granular
layer. And origin of hyaline layer, example:
= In humans,it is the product of Hertwig’s epithelial root sheath.
= Sometimes,there is no region between dentine and cementum (no
hyaline layer atall), instead thereis direct contact between the tubules
and the cementum fibres.

2- Attachmentto the periodontal ligament

- Fibres in the periodontal ligament run into the organic matrix of the
precementum. (Which means extrinsic fibres invade the cementum before
calcification).
- Then mineralization of the precementum leads to the incorporation of these
extrinsic fibres.
- These fibres are known as Sharpey’s fibres.

5-Resorption and Repair

- Generally, resorption may occur externally to the cementum or internally to
the pulp.

B0| Pace
 - Roots show small localized areas of resorption.
- These maybeassociated with trauma and pressure
applied onto these roots. (Unlike bone that undergoes
resorption normally).
- The cells responsible of resorption are multinucleated
odontoclastsoralso called cementoclasts. (These cells
formsby fusion of multiple number of macrophages;
because of that they are multinucleated).
- Resorption may reach dentine if the trauma was large; so
the size of resorption depends on the intensity of trauma.

- Resorption doesn’t go on forever in some pointit Aceiaiae

will stop and these deficiencies resulting from | cementum)
resorption can be filled by deposition of cementum, |
this new cementum is called reparative cementum
which always resemblesCellular cementum. But
the reparative cemntum is less mineralized and
“Dentin
have smaller crystals than normal cementum.
- The line where resorption stops and deposition
startsis called Reversalline.
- Precementum like layer (15m), wider than normal
precementum (5-10um), so the amount produced Reparative
per timeis larger which makesit thicker and clearer Seataien
than the normal precemntum. ie

True eaeaRU cea acyeeeCueCeolees

eanReEe ornareerMesRy Naatena)
CMEC CeCoN
SONIC Conkeel ee OROCOROolOLRCCL
eS Taelee eta RoC

NeueeeeRen aecu

ail Pace
 Periodontium 1

6-clinical consideration
Root fractures repaired by cementum callus.
Cementum callus: is a reparative cementum that continue forming outside
the root(extra) in case of horizontal fractures. With this extra formation it
lookslike a ring surroundingthe root.

Cementicles
It is a hard tissue similar to cementum formed SS
inside the periodontal ligament.
35% of human roots.
It may be attached (touching the surface of
cementum), free or embedded (if gets inside
cementum). (The one in the pictureis free).
Usually found near Apical and middle thirds of
the root. And sometimesnear Furcation areas
in case of multirooted teeth. '
They are asymptomatic and discovered
coincidentally.

a2| Pace
 Periodontium 1 L

e Hypercementosis
- Normally the thickness of cementum increases throughout life, but in this
case thereis over increase. This condition may belocalized(in one tooth) like
the pic on the right, or generalized(all teeth are affected) like the pic on the
left.
- The localized typeis usually causedby periapical inflammation following
pulpitis, then with healing process there would be this over formation of
cementum (hypercementosis).
- But the generalized type is caused by a systemic disease caused by genetic
defect, an example ofthese diseases is Paget’s disease of bone,in this
disease thereis also excessive formation of bone.

End of the Chapter

a3 | Pace
 periodontal ligament 5

The periodontal ligament

¢ Dense fibrous connective tissue that occupies the space between the
root and the alveolar bone.
¢ PDLis Continuouswith the gingival connective tissue and the pulp by
neural and vascular connections.
¢ Thereis a variation in the width of PDL accordingto:
- Location: being narrowestin the mid-root region, nearthe fulcrum
wherethe tooth moves when anorthodontic load (tipping load) is
applied to the crown.
- Age: PDL is narrower in permanentteeth than primary teeth and
with age, the periodontal space narrowsslightly.
- Function: PDL is increased in non-functional and unerupted teeth
(loose tissue) and is decreasedin teeth subjected to heavyocclusal
stress (tight issue).

PDL functions

« Provision of the tissue attachment betweenthe tooth and alveolar

bone.Thusit is responsible for tooth support andprotection. Patients,
whohavechronic inflammation in PDL, have mobility in their teeth
because the inflammation leads to destruction of the PDL, at the end
they will lose their teeth.
e Responsibility for the mechanism by whichthe tooth attains and
maintains its functional position; when you apply a heavyocclusal
load on your teeth, youwill feel pain that comes from PDL. This pain is a
protection mechanism to stop applying this load and avoid breaking your
teeth.
84| Page
a periodontal ligament

« Maintenanceand repair of cementum and alveolar bone;

cemetoblasts and osteoblastcells which are responsible to repair
cementum and bonerespectively; are locatedin the periodontal
ligament.

e Neurological control of mastication by its mechanoreceptors.

Periodontal Ligament components

1) Fibers: Collagen, Oxytalan

2) Ground substance
Ground substance (non-fibrous) = extracellular matrix - fibers
Extracellular substance contains fibrous and non-fibroustissue.
3) Cells: Fibroblasts, Cementoblasts, Osteoblasts, Osteoclasts,
Cementoclasts, Epithelial Cells (rest of malassez)

= very very important

*Wefind cementoblast and cementoclast on the cementum side.
Osteoblast andosteoclast on the boneside.
*Fibroblasts produce extracellular matrix (fibrous and non-fibrous)

I. Collagen Fibers
- Collagenfibers participate in the main portion of extracellular matrix.
Oxytalanfibers forms only a small portion ofit.
- 80% ofthe collagen fibers are type and 15% are typeIll and thereis a
small amounts of types V and VI
- Collagen typeIV whichis found in lamina densa andcollagentype VII
whichis found in anchoringfibrils form the basement membrane.

85|Page
 periodontal ligament a

- Tracesof IV and VII (basement membrane) are found usually around

rest of malassez and blood vessels (endothelial cells) where the
epithelial cells connect the connectivetissue.

- TypeXIl collagen: nonfibrous, linked to other collagens and may be

involvedin the periodontal ligament's architecture regulation.

- Muchofthe collagen(type | andIll) is gathered

into bundlesto form principalfibers (5um in
diameter).

- Sharpey’sfibers are the collagen fibers (principle

fibers) inserted into cementum and bone.
- Collagenfibrils are subunits within each principal
fiber. Fibrils show the classical banding of
collagen((triple helices)).
- Fibrils are 50nm in diameter (small and uniform)

- Sharpey’sfibers are
more numerous and smaller
at the cemental attachment
than sharpey’sfibers that
are inserted into alveolar
bone whichare thicker
andlargerin size.

Cementum
86|Page
7 periodontalligament

-The periodontal ligament fibers are named accordingto their

direction and location as follows:
Alveolar crest fibers (AC): because they are
attached to the alveolarcrest.
Horizontalfibers (H): because the direction of the
bundlesis horizontal
Oblique fibers (OBL): these bundlesgo in an
oblique direction
Apical fibers (PA): these fibers presentin the
apex of the tooth
Inter-radicularfibers (IR): these fibers presentin
the bifurcation area in the multi-rooted (molars and
premolars) wheretheroottrunk divides to give 2 or
moreroot.

Enamel E ——— Gingiva

Cementoename!
junction

Alveolar
crest fibers
| Alveolar
=| crest
Horizontal ae
fibers = Alveolar
bone
Dentin
- Haversian
Cementum . bone

Oblique % WF ¢
fibers J

rPyrIOnt aon 1 AM rights reserved.

87 |Page
 pe dontalligament

-The extentof individual fibers across the width of the

periodontal ligament:
1. Tooth related and bonerelated fibers that intercalate
in an intermediate plexus
2. Each fiber crosses the entire width (between the
cementum andalveolarbone)of the ligament
branchingin the wayto join neighbouring fibers to
form a 3D network

During tooth eruption, the periodontalligamentfibers changesits direction

to accommodatethe location andthelevelof the tooth by detaching and
reattaching to a newplaceora higherlevel.
The site where the remodelling of PDLfibers occurs during eruption
(detaching andreattaching) is called zone of shear. The most common
place for remodelling is the middle ligament.

-The principal fibers have a wavy course; andthis is actually good to

bearforces and avoid the breakageofthefibers.
-Fast turnoverof collagenin periodontalligament becauseofthe big load
andstress overthesefibers upon chewing andthefastest fibers of
turnoveris the root apex fibers where the largest stressis.

88 [Page
a periodontalligament

Oxytlan fibers
Oxytalan Collagen
Oxytlan fibers are immature elastin
fibers (pre-elastin). Their diameteris
between 0.5um-2.5um.

3% of PDL fiber composition and 97%

for collagen fibers.

- Attached to cementum andleaveto the

PDL ligamentin different directions and
terminate around blood vessels and
nerves, serve as cautions to protect BV
and nervesfrom large stresses and
sudden traumas.
Rarely incorporated in bone only attached to cementum in
opposite to sharpey’s fibers which crosses from the cementum to
the bone.Soif you see in anyhistological section Oxytlan fibers, you
should knowthatthis is the cementum side.

Oxytlan fibers have different course accordingto region.

Oxytlan fibers features comparedto collagenfibers:

Oxytlanfibrils (15nm in diameter) are unbanded arrangedparallel to the
long axis of the fiber but collagenfibrils are banded and arrangedin
triple helices.
No central amorphous core
Oxytlan fibers don’t have a role in tooth support where collagenfibers do
Oxytlan fibers may have role in fibroblast migration within the
ligament.

a9|Page
 periodontalligament a

lll. Ground substance

-Ground substance mainly secreted and degradedbyfibroblasts.

-Ground substanceis made upof:
1. Hyaluronate glycosaminoglycan
2. Proteoglycansinclude Proteodermatan sulphate and PG1 (contains
hybrids of chondroitin sulphate and dermatan sulphate)
3. Glycoproteinsincludes Fibronectin and Tenascin

« Ground substancefunctions
a. lon and water binding and exchange
b. Controlof collagen synthesis
c. Fiberorientation
d. Tooth support and eruption mechanisms(providing pressure) which
assistin the eruption of teeth.
e. Fibronectin may beinvolvedin cell migration and orientation

lv. Cells

PDL contains Fibroblasts, Cementoblasts, Osteoblasts, Osteoclasts,

cementoclasts, epithelial cells, and immune cells.

90|Page
yy periodontalligament

a. Fibroblasts

¢ Fibroblasts functions:
1) Responsible for the regeneration and turnoverof the periodontal
ligament.
2) Have a role in adaptive responses to mechanicalloading.
3) Secrets of matrix metalloproteinases andtissue inhibitors to
metalloproteinases
4) Fibroblasts produce collagenase which degradecollagenfibers and its
production is regulated by the exposure of cytokines.

Fibroblastfeatures:
- Fibroblasts show shapevariations and
manycytoplasmic processes.

- Low nuclear/cytoplasmic ratio. Meansthat

the nucleus size is small in comparison to
the cytoplasm size.

- Have a prominentnucleoli.

- Contain protein synthesizing organelles; ribosomes, Golgi apparatus

and rough endoplasmicreticulum.

- Localized movementoffibroblasts guided by §

collagenfibers. Chemotactic stimuli induce
this movement.
- Collagen degradation(fibroblasts are also
fibroclastic)
 periodontalligament S|

Fibroblasts are spindle shape

Intracellular collagen profiles
Acid phosphatase & cathepsins
Fibroblasts havecilia in their cytoplasmic
processes(9 tubule doublets)
Theyalso have intercellular contacts
(simple desmosomesandgapjunctions)

b. Cementoblasts

Theyline the surface of the cementum

Less elongatedthanfibroblasts. Cementoblasts are active cells but
they are less active thanfibroblast.
Their cytoplasm is rich. They have protein synthesizing organelles and a
large nuclei(butstill have low nuclear/cytoplasmicratio becauseit's an
activecell).
They have a Vesicular(circular) nucleus with one or morenucleoli.
Active cells have prominent processes(cellular cementum)
Cementoblasts which producecellular cementum have more prominent
processesthanthe cells which produce acellular cementum.

Cementoblats
92|Page
a periodontal ligament

c. Osteoblasts

- Theyline the tooth socket and exist on the

surface of the alveolar bone.
- Resemble cementoblasts
- Osteoblasts are prominent whenthere is active
bone formation
- The bone formation has 3 stages:resorption,
resting and bone formation by osteoblasts.
- Their cytoplasm is basophilic becauseof the
attached ribosomes on the RER. Theyare
cuboidalcells
- They have prominent basal round nucleus and
protein synthesizing organelles
- Inactive osteoblasts in resting stageare flat
andtheyarealso called bonelining cells. The
cell size guideusfor cell activity. Columnar cells are more active than
cuboidalcells and Flat cells are inactive.
- Also there are desmosomesand tight junctions between thesecells.
- Active osteoblasts may havefine cytoplasmic processes.

d. Osteoclast and cementoclasts

- Cementoclasts are also called odontoclasts

- Theyarise from blood macrophagesthat come from the bone marrow
whichis supplied by the blood.
- Howship’s lacunaein boneis where thesecells function on the
cementum or bonesurface.
- Small mononuclear macrophagesare fused to form a giant
multinuclear cemetoblastsor osteoclast.

93|Page
 periodontal ament

- Brushborder(ruffled border): Striated part of the cell (cementoclasts or

osteoclast) that is adjacent to bone/ cementum, they represent microvilli
to increase its contact surface area with the bone/cementum andthis
increasesits efficiency in resorption.
- They have manyvesicles with acid phosphatase enzyme.

e.Epithelial cells

- Epithelial cell is also called rests of Malassez \* ™®&

- Closely packed cuboidalcells NM,
- Variations in location according to age
- They appearas separate clusters in cross
sections near the cementum.
- In 3D they appearas a networkof strands
parallel to the long axis of the root.
- They are surroundedby basal lamina that
contains collagenIV and VII
- Thesecells are connected by desmosomesandtight junctions but they
are connectedto the basal lamina through hemidesmosomes.
- Thesecells are usually dormantbut they form Cyst when they
stimulated for unknown reason
94|Page
7 periodontalligament

iy
(A
a¢

f. Immunecells

1) PMNs(neutrophils)

2) Macrophages; 4% ofthe cell population, derivatives of monocytes.

-Macrophagefunctions: oe —
a- Phagocytosis and attacking organisms.
b- Productionof interferon, prostaglandin and
growth factors.

95] Pa
 periodontal ligament a

3) Mastcells; contain large number of granules, it’s very similar to the

basophils. The cell degranulates when stimulated to produce histamine,
heparin and anaphylactic factors. Over stimulation of mastcells causes
hypersensitivity.

Nerve supply of the periodontal Ligament

-The periodontal ligaments are innervated by:

1) Sensory nervefibers which transmit nociception (pain) and
mechanoreception (pressure and touch)
2) Autonomicnervefibers which control the diameterof blood vessels

-Nervefibers enter via the apical region of the ligament, while others
enter through Volkmann’scanalofthe alveolarwall to reach the PDL.

-Neverfibers can be:

*Myelinated (5m in diameter), and these are sensory fibers
*Un-myelinated (0.5ym in diameter), which can be sensory or autonomic
fibers.

- Myelinated sensory fibers transmit sharp andfast pain but un-

myelinated sensoryfibers transmit slow anddull pain.

96|Page
7 periodontal ligament

Special features of PDL

- Principalfibers have a specific orientation

- Different types and variations of Collagen
- Presence of Oxytalan
- Fast turnover rate
- Highly cellular and rich in ground substance
- Contains proteoglycan PG1 is specific to this location
- High hydrostatic pressure
- Unusualfibroblast features(cilia, contacts)
- Dental tissue formation cells; PDL has an ability to producedifferent
dental tissues like; cementum by cementoblasts.
- Rich vascular and nerve supply
- It contains fenestrated (perforated) capillaries

Fetal mechencyme

Similar properties between fetal mesenchymeandperiodontalligament:

- High rate of turnover
- Sharp, unimodalsize distribution of collagenfibrils
- High contentof collagen typeIII
- High volume of ground substance
- High contentof glucoronate rich proteoglycans
- High contentoffibronectin and Tenascin
- Presenceof oxytalan (pre-elastin)
- Highcellularity
- Hassimilar biomechanicalproperties to PDL

97|Page
 Alveolar bone
> Alveolar boneis the part of the jaw that supports and
protects the teeth.

The chemical composition of alveolar bone:

Boneis composed of 60% inorganic component, 25% organic

component and 15% water by weight.
¢ Inorganic composition:
Calcium hydroxyapatite Ca1o(POz)e(OH)2. Mainly carbonated
hydroxyapatite in the form of needle-like crystallites or thin plates.
e Organic composition:
Collagen (mainly type !) forms 90% of the extracellular matrix. There
are also serum proteins, acidic glycoproteins and small
proteoglycans.

The chemical composition of organic matrix:

1) Over 90% of the organic matrix is made of collagen fibrils,

mainly collagen typeI.
2) Proteoglycanssuchas chondroitin sulphate and heparan
sulphate glycosaminoglycans mainly in the form of decorin and
biglycan

3) Glycoproteins such as osteonectin, osteopontin,

thrombospondin, osteocalcin andfibronectin are also present

98| Pag
S| periodontal ligament

-Osteonectin can bind to calcium andthusis thought to be involved

in mineralisation
-Osteocalcinis only synthesised by osteoblasts and odontoblasts
-Exogenousproteins thatcirculate the blood and becomelockedin
bone suchascytokines and growth factors have an importantrole in
thelife cycle of bonecells
-Bone morphogenetic proteins (BMP)s are presentin bone.
There are8 proteinsin this family (BMP-1 to BMP-8). All BMPs are
part of the transforming growth factor beta (TGF-f) family except
from BMP-1.
-BMP(s) induce bone formation by influencing the movement,cell
division, and differentiation of stem and osteoproginatorcells.

Alveolar bonecells:

-Osteoblasts: Secrete the organic extracellular matrix of new bone

Osteoid (unmineralised bone) which rapidly undergoes
mineralisation to form bone, so we can’t see osteoid in histological
sections.
-Osteocytes: Osteoblasts becometrappedin bonein lacunae
-Osteoclasts: Multinuclearcells involved in bone remodelling and
resorption
- Bonelining cells (inactive osteoblasts): Flatcells line bone
surface during periods ofinactivity
-Osteoprogenitorcells: Stem cells beneath the osteoblastlayer
anddifferentiate to form osteoblasts.

99|Page
 periodontal ligament a

Osteoblast formation

a- Multipotent mesenchymalstem cells: which candifferentiate

to manykindof cells; adipocyte, fibroblast, chondrocyte...

b- Thenactivation of a certain genes will convert multipotent

mesenchymalstem cells to form Bi jotent mesenchymal
stem cells but their ability to differentiate to form different kinds
of cells is lower, so they can form or3 typesonly.

c- ThenBi-tripotent mesenchymal stem cells will form Committed

osteoprogentorcells which candifferentiate only to
osteoblasts

d- Activation of Runx-2 genewill convert the Committed

osteoprogentorcells to preosteoblast and then mature
osteoblasts

e- Osteoblasts will become bonelining cells (inactive

osteoblasts) in the resting stage. Ifit is trapped in the boneit will
becomeostyocyte.
Mutipotent and potent
mesenchymal mesenchymal eae Osteooyt!
stom col ‘Stomcels _cetopragentorcals Pre-osteobast Ostecblast ostocbiastapoposis
oocyte TAZ

tremeole Hah proteravepenta) Prtteraton

Siro
(ar ve) ype. | Set
ee
etogen Catagenpetv
PriPren

100 | Page
| periodontalligament

Alveolar bonestructure
> Woven bone is immature bone, with random organisation ofits
collagen. ‘Soit's a mineralized bonebutthe collagenfibers are
still unorganized’

> Lamellar bone Composedof successive layers (lamellae) It may

be formed as:
a- a solid mass (compact bone)
b- or disposedin an open sponge-like manner(cancellous bone)

Compact bone
Compactboneis madeofparallel bone columnswhich are
disposedparallel to the long axis of long bones(in line of stress
exerted on the bone)

Alveolar bone is composed of Osteonswhicharecalled

Haversian systemsthat includes a central canal called Haversian
canalthat contains blood
vessels, nerve bundles, fat
tissue, lymphatics and loose
connective tissue, this canal
is surrounded by concentric
lamellae of bone and the
cells are distributed within
these lamellae.

>Thedirection of the osteonsis parallel to the long axis of the

bone.

101| Page
 periodontal ligament a

Haversian canalswith their lamella form the haversian systems

(osteon)

Neurovascular bundlesof the osteons interact with eachother via

Volkmann’scanalsthat pierce the columnsatright angle or
obliquely to haversian canals

Osteocytesin their lacunae interact with each other and with the
central canal via cytoplasmic extensions (processes)in canals
called canaliculi

The outermostlayer of compact bonegives way to dense

cortical bone >> only the outermostlayer!
Compact bonefunctions:
1) Becauseofits position, compact boneacts as weight bearing
pillars
2) Compact boneis able to withstand high levels of mechanical
stress

The innermost aspect of compact bone, the lamellae merge with

trabeculae of cancellous (spongy bone)

Lacunae containing osteocytes Osteon of compact bone

Lamellae. Trabeculae of spongy
Canaliculi bone

Osteon . Haversian
ss x canal

Periosteum

Volkmann's canal

102 |Page
7 periodontal ligament

Spongy bone
- Cancellous (spongy) bone is madeof a network of bone
trabeculae separated byinterconnected spaces containing bone
marrow.
- Trabeculae are thin and composedofirregular bone lamellae.

- No haversian canals are presentin cancellous bone and

oscteocytesgettheir nutrition via canaliculi connecting them to
blood sinusoidsin the marrow.

- Spongy bonegivesboneitsflexibility due to the presence of

marrow spaces.

- Trabeculae arealigned alonglines of stress so as to withstand

forces applied to the bone while adding minimally to the
mass.
Soif our skeletal system is only made up of compact bone,it will
be so heavy and our movementwill be harder.

Decalcified section

103 | Page
 periodontalligament ,

Electron microscopy
¢ Inorganic preparations
- Active bone Deposition: small calcified nodules within and around
collagenfibrils
- Sharpey’s fibers appear as small dark circular areas
- Large ovoid areas represent lacunae
- Partially inorganic preparation: collagenfibrils parallel to the bone
surface

Thesepictures show the surface of active bone formation, you can

see the insertion points of sharpey’s fibers without the coverage with
mineralized tags. While in the rest stage, there are mineralization
tags on the bonesurfaceto fix sharpey’sfibers in its place inside the
bone.

This picture shows a bone surface ASN

in resorption stage and B represents .
Howship’s lacunae where the
osteoclasts were present.
7 periodontal ligament

Andin this stage the bone surface ==2S sm

appears as Jongesnail track
resorption lacunae.

This picture shows a resting

bone: projections marking the
sites of extrinsic mineralised
Sharpey’s fibers separated by
areaswith intrinsic mineralised
collagen.

You cansee thatthe insertion points of sharpey’s fibers become

more mineralizedto fix the fibers inside the bone. Also you can note
from this picture that there is resorption andresting areasin the
samesection andthistells you that notall the bone have resorption
or resting. Resorption and resting happenat the sametime in
adjacent areas!

Radiographic apparence
- The cortical boneis divided into outer and innerparallel alveolar
plates
- The outercortical boneis either lingual or
labial cortical bone.
- The innercortical bone: is the bonethat
surroundsthe roots ofthe tooth and called
tooth socket, cribriform plate or bundle bone
- It's called cribriform plate becauseit appears
perforated and contains many Volkmann’s _
canalsto connect the inner cortical bone with
PBL.
- It's also called bundle bone because the
sharpey's areinsertedintoit.

105|
 periodontal coment

- Sockets of 2 adjacent teeth are separated by interdental septa.

Roots of the sametooth are separated by interradicular septa.
- Fundus: the lowestlayer in the socketorthe socketfloor

- In radiographs, cortical bone

appearsasa thin whiteline
soit's called the lamina
dura. While spongy bone
appears grey becauseit’s
less dense and contains
bone marrow.
In the adjacent radiograph, the
arrowsare pointing toward the
lamina dura.

- Cribriform orinternalalveolarplate 0.1- 0.5mm in thickness

- External alveolar plates 1.5-3mm in thickness, so the external
alveolarplate is 6 times more thicker than theinternal alveolar
plate, variable around anterior teeth

Bone remodeling
Bone remodeling during humanlife occurs on 3 stages:
a- During childhood, bone deposition Bonewiin
exceeds resorption to allow the Nooial Bone Osteoporosis
growth of bones.
b- Equilibrium between bone
deposition and resorption in adult
life to preserve the bone mass
c- In old age, bone resorption exceeds
deposition so this will reduce the
bone massandlead to
osteoporosis.
7 periodontalligament

- Boneresorption factors affect mainly osteoblasts (not osteoclast)

to:
1) stimulate the production of osteoclasts by the releaseof
cytokines and growthfactors
2) produce enzymesthat degrade osteoid thus exposing bonefor
osteoclasts to work on
(Boneis protected by an osteoid layer which can’t be
destructed by osteoclasts, so osteoblasts produce enzymes
that removethis layer and allow osteoclast to break down the
bone.)

- Reversal lines marks the change in bone

activity as the adjacent picture shows.

- Constant remodelling is a normal and

continuous processto adapt pressure.
Firstly, bone resorption occurs then bone
enters the resting stage then bone formation
occurs.

- Spongy bone remodels 25% of its mass every year

- Compact bone remodels 3% ofits mass per year

>So the spongy bone remodels faster than the compact bone.

107 |Page
 periodontalligament a

Bone remodeling (continuous cycle)

[iiescence>
a>
isles Mesenchymal stem cell
Sa Monoonte x Old bone
Sirtave
Cementline.

Osteoid
Bonelining cells

1) Quiescence(resting state): in this stage the boneis lined by

bonelining cells (inactive osteocytes)
2) Boneresorption:activation of osteoclasts by osteoblast
occurs
3) Reversal: bone resorption by osteoclast stops
4) Boneformation: osteoblasts are activated in this stage
5) Mineralization for osteoid
Andthe cycle repeats...

Sharpey’sfibers
- Sharpey’s fibers are extrinsic ay
fibers, they enter the bone oak
perpendicularto the surface -JHS
- They are less numerous but rg
thicker than thosein
cementum.
a periodontalligament

Two main appearances under SEM (inorganic)

1) Fibers remain unmineralizedat their centres, resulting in hollow
centres (A)
2) Fully mineralised project beyond bone surface as small calcified
prominences(minerals tags) (B)

¢ Trans-alveolar fibers (A): are a type

of sharpey’s fibers which connect 2
peridontalligamentof different teeth
together and cross the whole thickness
of alveolar bone.

109 | Page
 periodontalligament a

Clinical considerations
A. Periodontitis: is a chronic inflammation of the peridontium
(gingiva, cementum, alveolar bone and PDL) whcih will lead to
the loss of periodontalligaments and alveolar bone, and without
treatmantthis mayleadto tooth loss. So periodontitis has to be
treated as soon a possible to preservethetooth.
B. Periodontal surgery.
C. Orthodontic loading:
In orthodontics, they depend on bone remodeling under pressure
to move the teeth and organizeit. So under the pressure we
have boneresorption but on the otherside (tension side)there is
boneformation.
D. Boneatrophy with decreased functional loads:
If someonehasa pain in oneside of his jaw and he eat on the
otherside, so this will lead to bone atrophyin the unfunctional
side.
E. Healing of extraction sockets:
Whena toothis extracted, at the begnning the socketwill be
filled with a blood clot, then this bloodclot will be replaced
gradually with bone by the activation of stem cells to differentiate
into osteoblast to form bone.

Blood clot

110| Page
[| periodontal ligament

F. Osteopetrosis:
is a pathological condition which results when the bone formation
exceeds boneresoption — opposite to osteoporosis, usually
these patients have a deffect in the osteoclast function while the
osteoblasts function normally so there is bone formation without
resorption andthis will increase the bone density.

G.Osteoporosis — disscused
earlier

H. Implants:
This type of treatment depends on
the osteointegration mechanisme.
The implants are made from
titamun metal which have the
ability to integrate with the bone
andfix the implant inside the bone
socket, this implantwill be covered
later with a crown.

111 |Page
 Oral mucosa /¥é
Oral mucosa
© The oral mucosa representsthelining of the oral cavity.
¢ It consists of oral epithelium and an underlying connective tissue
(lamina propria), and the basement membranein between.
¢ The oral mucosa ressembles the skin; the skin consists of 2 layers:
1) epidermis (whichis oral epithelium in oral mucosa)
2) Dermis (whichis the lamina propria in oral mucosa)
¢ The submucosa(in skin present as hypodermis)is a third layer that is
sometimes present betweenthe lamina propria and the underlying
boneor muscle.

Oral Mucosa Functions

Mechanical protection against compressive and shearing forces.
e A barrier against microorganisms and toxins.

« Humoral (antibodies) and cell mediated (T lymphocyte) immunological

defence.

¢ Minor salivary glands provide lubrication, buffering and antibodies secretion.

(usually present in submucosa)

¢ Input for touch, proprioception, pain and taste provided by its rich
innervation.
112 |Page
7 Oral mucosa

Oral Mucosa Components

1) Oral Epithelium
2) Lamina propria
3) Submucosa( which can be present or Lamina propria
absent)

¢ under submucosa may present muscle or

bone dependson the region

I. Oral Epithelium

¢ Stratified squamousepithelium.
¢ Keratinized or non-keratinized; Keratinized epithelium can be ortho or
para.
¢ Or : Ectodermal or endodermal. Mostofthe oral epithelium is
originated from ectodermal layer.

¢ Different layers accordingto keratinocyte differentiation.

113 | Page
 Oral mucosa S|

Keratinized epithelium layer: Ochre EN!

Stratum germinativum (stratum basale) Stratum germinativum (stratum basale)

(least differentiated) (least differentiated)

Stratum spinosum(prickle cell layer) Stratum spinosum (prickle cell layer)

Stratum granulosum (granularlayer) Stratum intermedium (intermediate layer)

Stratum corneum (keratinized orcornified Stratum superficiale. (mostdifferentiated)

layer). (mostdifferentiated)

114 | Page
7 Oral mucosa
The inner2 layers in keratinized and non-keratinized epithelium are
the same:

1) Stratum Germinativum (stratum basale)

¢ Single cuboidalcell layer, separated from the lamina propria by a basal

lamina.

¢ Progenitorcells of keratinocytes. (stem cells which differentiate into oral

epithelium)

¢ Mitosis confined to this layer.

« Daughter cells matures while ascendingto otherlayers.

¢ Basalcells divide under mitosis and give 2 cells, one of them remains
as a basal
resvoi andthe differentiate
into prickle cel.
==> In keratinized epithelium, prickle cell differentiates into granularlayer
theninto keratinized orcornified layer
==> In non-keratinized epithelium, prickle cell differentiates
into intermediate layer then into superficial layer.

« Stem cells are thought to be within the ridgesthat projectinto the

underlying lamina propria.

¢ Thereis diurinal variation in stratum basale’s mitotic activity; (means

mitotic activity varies during day and night).

¢ Basalcell layer are under Negative feedbackto inhibit further

maturation; because maturecells can’t be differentiated further soit
muststay as a stem cells to be able to differentiate into prickle cells.

115 |Page
 Oral mucosa a

iE Ne

2) Stratum Spinosum (prickle laye

Prickle cell layer consist of several layers.

Thecell shape is round to ovoid (polygonal) and the nucleus is round.

Thesecells are in the first stages of maturation andthey are Larger

and rounder thanbasal cells.

The cytokeratin expression processstarts at this layer. This

Cytokeratin contribute to the formation of tonofilaments whichis a
part of keratin layer.

In this layer, the synthetic activity is decreased.

Obland bodies: intracellular granulesrich in phospholipids.

The numberof desmosomes(a typeofcell junctions) in this layeris

higher than anyotherlayer.

116 | Page
7 Oral mucosa

¢ In histological sections, prickle layer appears Spiny dueto cell

shrinkage.(this is the reason forits name {stratum spinosum})

¢ Parabasallayers are the deepestlayersof prickle layer (the nearest

layer of the stratum spinosum to the basal layer).

¢ The first appearance of involcurin starts in this layers.

Involcurin: is a protein which has an importantrole in formation

Seinecoe

[>> The 2 outer layers of keratinized epithelium are:

1) Stratum Granulosum (granularlayer):

A. This layer has reduced organelles.

B. Their cells are larger and flatter and also they contain large
number of keratohyaline granules.(This is the reason forits
name {stratum granulosum})

C. They contain the precursortofilaggrin.

117 |Page
 Oral mucosa p

Filaggrin has an importantrole in formation keratin layer

2) Stratum Corneum (keratinized layer):

A. Lossofall organelles. (cell membrane filled with keratin)

B. Died cells
C. Filled with tonofilaments surroundedbyfilaggrin (keratin)
D. Keratin.
E. Desmosomesbetween thesecells are week; so this layer are
exposed to sheddingbutit can be repaired from the lowerlayers.
F. Epithelial squamesarethe cells whichis lost during functioning of
this layer, the nameof this process is desquamation.
G. The thicknessofthis layer is up to 20 cells.

>> Thenormalthicknessforthis layer from to 4 layers but in some

pathological cases (cheekbiting, bridges, or composite that cause a
continuous friction on the cheekwill induce formationkeratinized layers
for protection) the thicknessof this layer may reach to 20layer.

TMRee atm aMette Mei

keratinized.

118 | Page
7 Oral mucosa

H. Para-keratinised epithelium has piknotic nuclei (small deeply

stained nucleus) in the stratum corneum.
1. Ortho-keratin (no remnantsof piknotic nuclei).

leeieee
(pathologically induced)

etetec

119| Page
 Oral mucosa S

Non-Keratinised Epithelium features:

a. Non-keratinised lining epithelium.
b. Less developed tonofilaments.
c. Lack of keratohyaline granules. (becauseit lacks to the
granular layer)
d. Stratum intermedium and stratum superficiale in non-keratinized
epithelium instead of stratum granulosum, stratum corneum in
keratinized epithelium.

Oral Epithelium Phenotypes

* Thetype ofepithelium to keratinized or non-keratinized could be

determined by:

1. External stimuli especially from the underlying lamina propria

(epithelial-mesenchymal interaction). -more supported-
That meansif we take a cheek epithelium which is non-keratinized
andputit in the hard palate region (normally keratinized
epithelium) above lamina propria layer this non-keratinized
epithelium will receive messagesfrom lamina propria to form
keratinized layer that is related to the function ofthis region
(protection againstfood friction).
2. Innate Properties within the epithelial basal layer.

120|Page
7 Oral mucosa

Non-Keratinocytes-clear cells-(within the Epithelium):

© 10% oftheoralepithelial cells are non-keratinocytes(notoriginated
from keratinocytesit’s originated from different place then migrated
andsettle within the epithelium)
@ Thesecells lack Cytokeratins and appear asclearcells in H&E
stained sections
e Whyis it namedasclear cells? Becausetheir cytoplasm can’t be
stained by haematoxylin and eosin stain but their nucleusdoes.

Non- keratinocytesare 4 types:

1)Melanocytes 3) Langerhanscells
2)Merkel cells 4) inflammatory cells

421 |Page
 Oral mucosa -

Melanin producingcells.

Situated within the basal cell layer or slightly aboveit.

Neural crest derivatives(their origin).

Thesecells have long processes.

Melanin is produced usingtyrosinase.

Tyrosinase: is an enzymethat converts tyrosine amino acid to melanin

Protein synthesizing organelles —RER and Golgi apparatus-. (Because

tyrosinase works on tyrosine residues not on free tyrosine amino
acids).

Melanosomes:arevesicles where the melanin will be stored.

reepee
reaataity

DOT Tur

& ae

122|Page
7 Oral mucosa

¢ Each melanocyte can contact up to 40 keratinocytes by their

processes;
- Keratinocytes release mediators important for melanocyte
function. (send messages to the melanocytesto increase or
decrease the production of melanin pigment)
- Keratinocytes take up melaninbyactively phagocytosing the
melanocyte’s dendritic tips (these tips contains melanosomes) in
this way keratinocytestakes keratin whichis important for
protection from harmful radiation especially UV that cause
mutationsand this explains why wefind thesecells in the basal
layer that divides continuously.

© The degree of pigmentation(the colour ofthe skin light or

dark)is affected by:
1- The size and degree of branching of melanocytes(rather than by
the number ofcells).
2- The size of the melanosomes.
3- The number and degreeof dispersion of melanosomes.
4- The degreeof melanisation of the melanosomes.
5- Degradationrate of the pigment.

123 |Page
 Oral mucosa _

*NOTE: racial pigmentation(clinical term): dark spots appear on the

gingiva because of extra formation of melanin pigment whichleads to
leakage of this pigment to under laying connective tissue (smokingis the
common cause. If the patient stops smoking these spots disappears
gradually) —in histology this case is named as melanin incontinence-

Eee

¢ Langerhansare dendritic and antigen presentingcells (these cells

binds to the antigen in the epithelium then migrate to lamina propria
and presentthis antigen for the lymphocytes to cause immune
reaction and getrid of the foreign body).
© Abovethebasal cell layer (in stratum spinosum —prickle layer-).
© Derivatives of bone marrowprecursors, they leave the blood stream
and enter the lamina propria before penetrating the stratum
germinativum.
¢ Chemokinessecreted by keratinocytes act as chemotactic factors to
attract the Langerhanscells to enter the epithelium layer.

124|Page
7 Oral mucosa

© They Movetolocal lymph nodesvia dermal lymphatics.

© They have ATPaseontheir cell membrane.
Langerhanscells contain Birbeck granules that appear under EM
image rod shaped.( related to antigen presentation)
Interaction with T lymphocytes.
Functions:(binds to any foreign body,
1. Theyplay an important role in contact hypersensitivity reactions of
the skin. (allergic reactions)
2. They have a role in anti-tumour immunity.
3. Theyalso havea role in graft rejection.

mam) Wherethereis any defectin the oral tissue and we do an

implantation in this specific region, Langerhanscells consider this
tissue is a foreign body and rejectit (responsible for graft rejection).

lamp If the graft tissue which will implant taken from the sameperson,
the percentofrejection is lesser than if we take it from another person.

4. They react as propagators of HIV-1 transmission toT cells.

EM image
LM image(special
stain) because it
can’t be stained
with H&E

125 |Page
 Oral mucosa o

Tey

Foundin the basalcell layer, close to

nervefibres.
Acts as a receptor.
Neural crestderivative.
They contain CK8/18 and 20 (in small
quantities that can’t attract H&E stain.
Commonin masticatory mucosa,
absentin lining mucosa.(only present in
keratinized epithelium)
Deeply invaginated nucleus.
Nuclear rodlet.
Mitochondria, free ribosomes and granules.
Merkelcells Vesicles contains neurotransmitters adjacent to nerve.
When thesecells exposedtofriction or any other stimulator they release
these neurotransmitter in the adjacent nerve and cause action potential

Inflammatorycells(

In normal situation you can’t find thesecellsjustif there is an

inflammation, thesecells will migrate to the epithelium.

126 |Page
7 Oral mucosa

Il. Lamina propria

Laminapropria is the 2" componentfor the oral mucosa,it consists of
two mainParts:

1) Superficial papillary layer (loose thin collagen fibres perpendicular

to the surface).

2) Deepreticular layer (thick collagen bundlesparallel to the surface).

¢ Also lamina propria containsfibroblasts, immune cells (histiocytes,

mast cells and lymphocytes).
¢ Extracellular matrix for lamina propria consists of :

I. Collagen (90% type |, 8% typeIll).

ll. Small amounts of non-fibrillar collagen.

Ill. Elastin, oxytalan.

IV. Proteglycans and glycoproteins.

TTTai
Mey oelay Deep
alles
layer

127|Page
| Oral mucosa

Epithelial Connective Tissue Interface (basement membrane)

Connectstheoral epithelium with the underlying lamina propria

Basal lamina (this term used in Electron microscope image)

Basement membrane(this term used in Light microscope image).

Composeoffibrils and ground substance.

Basement membranecontains three zones:

a- Laminalucida(light): (20-40nm thick), immediately under the

epithelium. It’s made oflaminin (glycoprotein). Lamina lucida attached to
the hemi-desmosomesthat exist in the basal layer through laminin
glycoprotein.

b- Lamina densa (dark): (20-120nm thick) is madeof type IV collagen

coated with heparin sulphate,fibronectin is sometimes found in the
lamina densa and maybind fibroblasts and proteoglycans toit.

c- Fibroreticular lamina (anchoringfibrils): some references consider

this layer as a part from lamina densa.

© Most componentsofthebasal laminaare synthesized by epithelial

cells not by lamina propria.

¢ Laminin cementstype IV collagen between the lamina densa and the

epithelial cells.

¢ Laminin from lamina lucida is attached to collagen type IV that exist in

lamina densa

128 | Page
 Oral mucosa -

© CollagentypeIV is attached to collagen type VII (anchoringfibrils)

that exist in Fibroreticular lamina

¢ Thick collagenfibres (collagen type |) attach to the lamina densa

(collagentypeVII) to link the basal lamina to the connective tissue.
[Collagen type | and typeII from lamina propria make hokes with
collagen typeVII (anchoringfibrils)]

© NOTE:Theroleof the basal lamina:

a- Provide mechanical adhesion between the epithelium and the

connectivetissue.
b- Molecular barrier.

c- Has a rolein responsetoinjury.

Lamina lucida
Lamina densa

‘Anchoring fibrils

—~Basal coll
Tonofilaments
Hemidesmosome
Lamina lucida
Lamina densa
‘Anchoring fibrit
>coltagen fibrits
D>

129 |Page
 Oral mucosa

Ill. Oral sub-mucosa

© Oral sub-mucosais a layer of loose fatty or glandular connective

tissue.
¢ The submucosa sometimes present between the lamina propria and
the underlying bone or muscle and sometimesnot.

¢ This layer contains major blood vessels and nerves supplying the
mucosa and separatingit from underlying bones and muscles.

© The composition of the sub-mucosa determinesthe flexibility and

mobility of the mucosal attachment to underlying structures{if sub-
mucosa doesn’t present, mucosafirmly attached to the underlying
boneor muscle (no mobility)}.

Minor salivary glands of both mucousand seroustypesand rarely

sebaceousglandscan bepresent.

- NOTE: minorsalivary glands in sub-mucosacan be:

1) Completely mucous

2) Mixed (mucoserous) -mucous more than serous-

3) Completely serous only in von Ebner gland associated with circumvallate

papillae. It’s location just anterior to the sulcus terminals which determines
the boundary between the anterior 2/3 and posterior 1/3.

© Nodulesof lymphoid tissue can also be seen.

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 Oral mucosa -

Regional Variations

Regional variations dependingonits function, the oral mucosa differs

regionallyi

¢ Epithelial thickness.
© Keratinisation; to be ortho or para keratinized or non-keratinized)
© The complexity of the epithelial connective tissue interface. [The
shape of the rete-ridges and connective tissue papilla to be pointed
(finger like), shallow and short or square].
© The composition of the lamina propria.
¢ The submucosa(present or absent) and if it is present,it differs in the
typeof the tissue that it contains to be fatty or glandular or lymphoid
tissue.

Oral Mucosatypes
Depending onthelocation and function of the epithelium,the oral
mucosaeareclassified into:

1) Masticatory oral mucosa

¢ Areas subjected to high compression and friction from food

© Covers parts of the hard palate and thegingiva.

© The epithelium is always keratinized (ortho or para) becauseit’s

exposed to high compression andfriction.

© Thick lamina propria

431 | Page
| Oral mucosa

2) Lining oral mucosa

© Not subject to high levels offriction.

¢Mobile and distensible.

Coversthe oral side oflips, cheeks, alveolar mucosa,soft palate,

ventral surface of the tongue andthe floor of the mouth.

The epithelium is non-keratinised.

eLoose lamina propria

3) Specialized mucosae:
Twoof them are keratinized:
a- The dorsal surface of the tongue (anterior 2/3 of the tongue
dorsant)
b- Vermilion border (zone) /lips.

Andtheother two are non-keratinized:

c- The lingual tonsils (posterior 1/3 of the tongue dorsant)

d- The gingival attachmentto teeth (junctional epithelium: connects

the gingiva to enamel).

Anytissue that is not specialized or masti ry it’sa

lining tissue.

132 | Page
 Oral mucosa -

The Lip
Vermilion zone(transition, red zone).

labial mucosa on theinnerside

Minorsalivary glands
(mixed but mainly mucous)
in the submucosa.

Striated musclesof facial expression in

the lip core (orbicularis oris).

NOTE: Minorsalivary glands in the anterior oral region

is mixed but mainly mucous,in the posterior region are
completely mucous ed

ERs
b- Vermilion border (red zone)
c- Oral side
areata ELCs

133 | Page
@ The Lip Skin

v Skin ofthe lip has a thin keratinised epidermis

Y Connective tissue dermis.

v Hair follicles= C
v Sebaceous glands =B

v Sweatglands=A

e Vermilion Zone

Y No skin appendages(hair follicles, sweat or sebaceous glands).

Y Occasional sebaceous glands (corners of the mouth).

v No mucous salivary glands.

v Keratinised, thin translucent epithelium.

v Lamina propria highly vascular — this explains red appearanceclinically- ,
has capillary loops and attached directly to the muscle (no submucosa).

134|Page
 Oral mucosa Z

*Note: usually salivary glands present in submucosa exceptin the ventralside

of the tongue,salivary glands presentin the tongue muscle.

Y The junctional region between the vermilion zone and the labial mucosais
knownas the intermediate zone (contact point between vermilion zone and oral
side ofthelip).
¥ Intermediate zone is Parakeratinised.

v Intermediate zone is notclear in adults but in infants, because of breast

feeding it becomes thickened and forms the suckling pad.

a- Vermilion zone (thin keratinized

epithelium)
b- oral side (thick non-keratinized )
c- orbicularis oris muscle.

¢ Labial Mucosa
Y Thick non-keratinized epithelium.

Y Wide lamina propria with short and irregular papilla.

Y Submucosa with many minor salivary glands (mixed mainly mucous).

135 |Page
a Oral mucosa

v Dense connectivetissue fibres bind the mucosatothe orbicularis oris

muscle (supporting the lip)

a- thick non-keratinized epithelium

b- Lamina propria
c- Minor salivary glands
d- Orbicularis oris

e The Cheek
v Buccal mucosa (oral side of cheeks).

v Lining mucosa.

v Non-keratinised epithelium with dense lamina propria.

Y Submucosa with many minor salivary glands (mixed mainly muocus).

v Buccinator muscles beneath the glands (for support).

A-basal layer
B- Prickle layer
C- Oral cavity
D- Superficial layer
E- Intermediatelayer

Bl Page
 Oral Mucosa II

Gingiva
‘© Gingivais the portion of the oral mucosathat surrounds and is attached to
the teeth.
© Gingiva is divided into two main regions:
1) The attached gingiva (A): directly bound to
the underlying bone or tooth structure.
Firstly, the gingiva is attached to enamel
then to cementum of the tooth and finally
to the alveolar bone. (from the highest to
the lowestpoint)
2) The free gingiva (D): narrow, not bound to
any bone ortooth and it’s coronal to
(above) the attached gingiva.

The gingival margin (F) is the coronal limit of

the free gingiva.
The gingival sulcus (G) is the unattached
region between the free gingiva and the tooth.
In healthy gingiva, the gingival sulcus is about
0.5-2.0mm deep. If the sulcus is between 2-
3mm deep,it is a beginning for periodontal
pocket.
If Sulcus is deeper than 3.0mm, it is considered
as a periodontal pocket whichis a sign for
chronic periodontitis.
The junctional epithelium (H) is the area
wherethe gingiva is bound to the tooth.

138|Page
| Oral MucosaII

The free gingival groove(E) that demarcates the free from the attached
gingiva externally -away from the tooth- and presentsin only about 40% of
teeth. When present, the free gingival groovelies approximately at the level
of the cement—enamel junction.

Free gingival groove follows the contours and morphologyof the

cemento-enamel junction (cervical line) and goesparallel toit. It may be
producedbythe bundlesofprincipal collagen fibres that run from the
cementumtothe gingiva, or may correspond to a heavyepithelial ridge.

The principle fibers of gingiva may run from cementum to cementum, or

from cementum to alveolar bone andbind externally. If the fibers bind
internally to the alveolar bone, they will be periodontal ligament fibers
notgingival fibers.

Healthy attached gingiva often showssurface stippling, which

correspondstosites of deepepithelial rete-ridges.

Heavyepithelial ridges.

_Interdental
Inter-dental papilla fills the
space between the teeth below
the contact point. It has two
parts, attachedand free inter-
dental papilla.

139| Page
 Oral MucosaIl o

D: attached gingiva

E: free gingiva
F: inter-dental papilla

And the blackline showsthe free

gingival groove

Attached gingiva
* The external surface of the attached gingiva
is masticatory mucosa. It is either ortho or,
para keratinized and the degree of
keratinization varies considerably between
andwithin individuals.

* 75% of the surface maybe parakeratinised.

* The gingival rete-ridges show variation to

be longor short butall of them resemble pointed finger-like
projections.
* Thepart of the attached gingiva that is being bond directly to alveolar
bone without submucosa is called mucoperiosteum

> Muco means mucosa, mucosa= lamina propria + epithelium

> Periosteum a layer that covers bonedirectly without
submucosa

140 | Page
7 Oral MucosaII

* The junctional epithelium

is the internal part of attached
gingiva because it is attached to
enamel, cementum and alveolar
bone,respectively, from the top to
the bottom.

* Externally, the free gingival

mucosa is similar to the attached
gingival mucosa in:
1) The epithelium whichis Dentin Enannel
stratified and keratinized space
squamous epithelium
2) Thereteridges (finger-like Sulcular
projections).

Sulcular epithelium
* Sulcular epithelium starts from the sulcus base to the gingival margin.
* Sulcular and junctional epithelia form the gingival cuff.
+ Sulcular epithelium has a more folded interface with the lamina propria
(which meansit has heavyrete-ridges).
* Sulcular epithelium is thin and non-keratinized but the junctional
epithelium is also thinner than the sulcular epithelium.
* Thebaseofthe gingival sulcus is at the samelevel as the free gingival
grooveexternally.

141 | Page
 Oral Mucosa II S|

Junctional epithelium
+ Junctional epithelium extends from CEJ to the sulcus base(the beginning
of sulcular epithelium)
* Normally, junctional epithelium is about 2mmlongin fully erupted teeth
butit’s longer than 2 mm in partially erupted teeth.
+ starts
+ Junctionalepithelium has 2 layers only; Startum basale and Stratum
spinosum. while Sulcular epithelium hasthe4 layers; stratum basale, stratum
spinosum,stratum granulosum,stratum corneum.
* The junctional epithelium hasa high rate of turnover (5-6 days)

* Junctional epithelium is originally derived from the reduced enamel

epithelium/ enamel cuticle (same CKprofile).

+ Junctional epithelium has smooth connective tissue interface (doesn’t

haverete-ridges in contrast to
sulcular epithelium)

* 2 basallaminae: internal which Lamina

is near the tooth side and a
external whichis away from the
tooth side. e 4
~ Basal Lamina Basal Lamina
‘internal (Esteral)

142| Page
7 Oral MucosaIl

* The external lamina densa is located between the epithelium and

lamina propria. While Lamina densain the internal lamina is not
clearly delineated,it lacks type IV collagen and laminin.

* Inthe junctional epithelium, smaller number of desmosomes that

connectsthe cells result in spaces making up to 5% ofthe tissue
volume. Thesespaces facilitate crevicular fluid movement.

* Crevicular or sulcular fluid and immunecells pass through these

spaces
* The length of the junctional epithelium varies with the stage of
eruption; when the tooth first erupts, most of the enamel is covered
with junctional epithelium. By the time the tooth reachesocclusion, %
of the enamelis covered. Later on, the junctional epithelium will lie
close to the CEJ.

* Gum recession leads to apical migration and the junctional epithelium

won't bestart at the level of CEJit will be at a lower level and contact
the cementum instead of enamel.

Gingival
epithelium
Sulcular
epithelium:
This arrowis pointing at the base of
gingival sulcus wherethe changesin the
epithelium thickness and rete-ridges
heaviness occur. At the samelevel externally
free gingival groove may present.

143 | Page
 Oral MucosaIl -

Howtodistinguish the junctional epithelium from

sulcular epithelium?

1) Histologically, the sulcular epithelium (internal free gingiva) may be

distinguished from the junctional epithelium (internal attached gingiva)
by having a morefolded interface (heavy rete-ridges) with the
underlying connective tissue.

2) In addition, tags of an enamel cuticle may be seenat the interface

between the twoepithelia.

3) The twoepithelia can also be distinguished by their different

cytokeratin profiles because every epithelium has different origin

4) The junctional epithelium is also thinner than the sulcular

epithelium

GS: gingival sulcus ‘

OSE: oral sulcular
epithelium
JE: junctional epithelium
E: enamel; ES: enamelspace j
D: dentine C: cementum ie
OE:oral epithelium

Copyright © 2002, Mosby, In., Al ights reserved,

144 | Page
7 Oral MucosaII

Cervicular fluid
= The dentogingival junction seals the lamina propria from the oral
environment.
= The gingival crevicularfluid is the fluid within the sulcus.It results from
the permeability of the junctional epithelium.
= Material pass from the lamina propria into the sulcus.
= It contains polymorphonucleocytes (neutrophils) so it has an important
role in the defence mechanism against foreign bodies.

Interdental papilla
= The interdental gingiva occupies the area betweenadjacentteeth.
Its shape and size depend on the shape and contact between teeth.

Interdental
It’s wedge shaped appearance
onthe buccal andlingual sides
It’s pointed betweenanterior
teeth anditfills the contour
aroundthe contactpoint.seethe
adjacentpicture >

The interdental col is a curved

depressionacross the buccolingual
plane in posteriorteeth. (There is 2
gingival triangles buccolingualy in the
posteriorteeth, the first one buccualy
and the 2" lingualy and the colis the
depression between these2 triangles.

145 | Page
 Oral MucosaII -

e The epithelium of the col is continuous with

the junctional epithelium. So they have the
same features; thin, without rete ridges
(smooth interface), non-keratinised,
initially derived from the reduced enamel
epithelium.

e Spaced teeth haveno col, they have a thin keratinised gingiva instead
because of the foodfriction.

The Gingival Lamina Propria

Gingival lamina propria is a dense collagen bundles.

© Gingival lamina propria functions:

1) support the free gingiva.

2) Bind the attached gingiva to the alveolar bone and the tooth.

3) Linkage of teeth to each other.

¢ Principal fibres divided into groups accordingto their location.

a. Dentoginigval fibres.
. Longitudinal fibres.
samt oanos

Circular fibres.
. Alveologingival fibres.
Dentoperiosteal fibres.
Transseptal fibres.
Semicircular fibres.
. Transgingival fibres.
Interdental fibres.
j. Vertical fibres.

146 | Page
7 Oral MucosaII

As you can seein thepictures below,

- The dentogingival fibers run from the cementum to the lamina propria of
the gingiva.
- The alveolgingival fibers run from thecrest of the boneto thegingival
laminapropria.
- The dentoperiostealfibers run from the cementum to the alveolar crest
but binds externally. So it’s not considered as a part of PDL
- Circular fibers surround the tooth.

«Buccal Dentogingival
group

group Alveologingival
group

Alveolar Bone

Transseptal fibers (F): these fibers run from

the cementum of a tooth to the cementum of
the adjacent tooth. =

187 |Page
 Oral Mucosa Il :

A= Dentogingival
B = Longitudinal fibres runs along the arch
C= Circular fibres. |
D = Alveologingivalfibres
E = Dentoperiosteal fibres.

1 = interdental fibers
J= vertical fibers

G = semi-circular
H = transgingivalfibers

148 | Page
7 Oral Mucosa Il

- Compared to the periodontal ligament:

The fibroblasts of the gingiva lamina propria lack alkaline phosphatase.

They have less contractile proteins

They can release more prostaglandin in response to histamine.

* Less ground substance.

* Less type Ill collagen.

+ Lower turnover rate.

* Rich vasculature, 2 plexi beneath the oral sulcular epithelium and

beneath the oral gingival epithelium.

The alveolar mucosa

e The attached gingiva is

demarcated from the alveolar
mucosa by the mucogngival
junction.

Mucogingival junctionis located ction,

3-5mm belowthe alveolarcrest. Bee eerie)
Alveolar crest is below the CEJ.

© The alveolar mucosa is more reddish in colour than the gingiva, because
it has more blood supply and it’s covered bythin epithelium in contrast
to the gingiva which appearspale in colour because it’s covered by thick
and keratinized epithelium.

149 | Page
 Oral MucosaII o

It lines the lowerpart of the alveolus orthe alveolar bone and the
upper part is covered by the attached gingiva.

Alveolar mucosa is absent on the palatal side.

Hasa looseand elastin submucosa, whichis attached to the

periosteum.

It’s covered bythin translucent epithelium, non-keratinised.

Blood vessels near the surface soit appears reddish

Contains minorsalivary glands in the submucosa layer.

Alveolar Gingi
deny

The palate
The palateis divided into 2 main areas:

|. The hard palate is supported by bone

ll. The soft palate is supported by muscles

150 | Page
 Oral MucosaII

i. Hard palate
* The hard palateis lined by masticatory mucosalike the gingiva.

Thehard palate is coveredby keratinised epithelium.

* No submucosain the central region

Bone

Lamina
propria

Epitheluim

Asyou can seein the picture above thatis taken from the medportion of
the hard palate (Medline palatine raphe), there is no submucosa.

+ Asubmucosa exists where the palate meets the alveolus.It contains

the main neurovascular bundle this region is called the inscive papilla
which is the most anterior part of the med portion of the hardpalate.

* The neurovascular submucosa contains; nasopalatine nerve,

nasopalatine artery and nasopalatine vein.

* Fovea palatinae is supported by general submucosa

* The submucosa ofthe posteriolateral hard palate contains minor

salivary glands (completely mucus)
* The submucosa of the anteriolateral hard palate contains adipose
tissue (fat).

151| Page
 Oral MucosaIl o

- You can seein the adjacent

picturethat is taken from the
anteriolateral region of the hard
palate thatthe rete-ridges
notfinger like projection as the
rete-ridges of the gingiva. Also its
submucosa contains adipose
tissue.

- The palate separatesthe oralcavity from thenasal cavity so it has nasal

surface and oral surface which is divided into hard palate and soft palate.

- Beneaththerespiratory thereis
vascular submucosathat
containslarge veins to warm up
thecold inhaledair before enter
thelungs. Also the submucosa
\ contains minorsalivary glands.

152| Page
| Oral MucosaII

ii. Soft palate

The mucosa covering the oral surface Hard

of the soft palate is a non-keratinized Taste palate
lining mucosa

© It has a short broad connective tissue

papillae.

Submucosa with manysalivary

glands completely mucus.
3
ees

Floor of the mouth

- Both thefloor of the mouth and theventral (lower) surface of the tongue
have a typicallining mucosa. is
- Aneedfor mobility.
- Thin, non-keratinized epithelium with shortpapillae.
- Submucosaconsiderablefor the floor of the mouth and contains major
salivary gland whichis called sublingual salivary gland which is mixed but
mainly mucus, but submucosaalmost absentfor the ventral surface of
the tongue. Beneath the epithelium of the ventral surface of the tongue
there is lamina propria and a muscle, within the substanceof the muscle
there is a gland whichcalled anteriorlingual gland andit’s a minorsalivary
gland (mixed but mainly mucus).

153 | Page
 Oral MucosaII /

a route by which somedrugscan rapidly

reach the blood stream. Ex; nitroglycerine
for angina pectoris has a rapid and
effective effect in vasodilation.

Dorsal surface of the tongue

* The anterior 2/3 are divided from theposterior 1/3 by the sulcus
terminalis (v-shaped).

The anterior 2/3 of the tongue are covered with papillae and covered
by keratinized epithelium (specialised mucosa).

Theposterior 1/3 has lots of lymphatic nodules

The posterior 1/3 of the tongue is covered bylining mucosa (non-

keratinized epithelium), except the lingual tonsil area which is covered
by specialized mucosa.

There are 4 maini typesofpapillae

i gaat wea_. ePiglottis
covering the dorsal surface of the palatine tonsils
tongue:

Filiform papillae. sulcus terminalis

Fungiform papillae. vallate papillae
Foliate papillae. foliate papillae
Circumvallate papilla. fungiform papillae

filiform papillae:

154| Page
| Oral MucosaII

a.Filiform papillae
Filiform papillae covers

They have a central core of lamina

propria with secondarypapillae
branching from it.
They have a mechanical function in
mastication astheyare highly abrasive and they don’t havea role in
tasting as they don’t havetaste buds.

The picture above shows the anterior 2/3 of the tongue which contains a
thin lamina propria and beneathit directly there is a muscle so the
submucosais absent.

b.Fungiform papillae
Fungiform papillae are found as isolated
elevated mushroom shaped papillae,

They are 150-400um in diameter.

Covered with thin epithelium, slightly

Contain vascular and thick lamina propria

coreso it appears red in colour.

Taste buds could be foundonthesurface.

155 | Page
 Oral MucosaII :

c.Folaite papillae
- Foliate papillae may be found as
Epithelium Taste Bud
1-2 longitudinal clefts the

tongue. (Vertical ridges and

grooves)

- Taste buds maybefound within

their epithelium on the groove
sides. Foliate Papilla

d.Circumvallate papillae
- Circumvallate papillae are large Circumvallate
and rounded. papilla
- Theyarelocatedjust anterior 1

- Theyare approximately 12 in
number
- Surroundedby a trenchlike
structure -deep grooves. These a / i; Muscle j ;
trenchesare associated with special glands which are called Von
Ebner’s serous glands. (Completely serous)
- Contain the highest numberof taste budson theinternal wall of
trenches
- Theyare not projected beyond the surface ofthe tongue.
- Covered

156 | Page
7 Oral MucosaII

- Von Ebner’s glandare the only minor salivary glands which is completely
serous; mostof the minorsalivary glands are mixed but mainly mucus or
completely mucus.

- Von Ebner’s gland functions:

1) Von Ebner’s serous glands emptyinto the baseofthe trenchto flush it

andavoid the accumulation of food andbacteria.
2) Also the seroussecretions dissolute the chemicals of the food to ease
the taste sensationin taste buds.

> In the posterior 1/3 of the tongue dorsum,there are minorsalivary

glands completely mucusin the submucosawithin the musclefibers

157| Page
 Oral Mucosa II -

Taste buds
* Taste buds are the chemoreceptive organ oftaste.

Exist in circumvallate, fungiform and foliate papillae, in addition to the

palate andthe epiglottis.

A small taste pore opens from the surfaceinto the bud to allow the
food entrance.
Consist of two main typesofcells:

1.Taste cells.
2. Supporting cells.

Four sensory taste cell types:

A- Type | cells appear dark.

B- Type II cells appear light.
C- Type Ill cells appear light.
D- Type IV cells are undifferentiated
(stem cells for the other types),lie
basally and possess intermediate
filaments

* Types | and Ill form synapses with the

intrageminal nerves.
* A basal lamina separates the bud from the
lamina propria.

158 | Page
7 Oral MucosaII

outertaste pore
epithelial
A
a

synapses

Lingual tonsils
* Massesoflymphoidtissue onthe the

+ Lingual tonsils are a part of Waldeyer’s ring, which is formed bylingual,

palatine and pharyngealtonsils.
* Lingual tonsils have deepcrypts lined with epithelium containing
massesoflymphoidtissue.
* Also mucous glandscould be present in the submucosa.

Lumenoforal

159 | Page
 Oral MucosaIl /

Clinical considerations
© Changes in CK expression due to inflammation.
© CKin diagnostic histopathology (poorly differentiated neoplasms).
© Dysplastic changes revealed by CKalterations. Dysplastic means the
changes that occur before the occurrenceof cancer, so we can predict
thattherewill be cancer in this tissue from the changesin CK.
© CKin determining the origins of cysts.
© Gingival woundsdo notform scars upon healing, resembling by that
foetal mesenchyme; gingiva has a high generation ability and it can heal
without leaving a scar, this characteristic is similar to mesenchyme.

160 | Page
 Oral Embryo

Developmentof the face

The face developsin the human betweenthe 4"and 10' weeksof intra-uterine
life.

*Stomodeum: Primitive oral cavity

« 4week in utero
Stomodeum is bound byfive
facial swellings:

-Frontonasal process (A)

-2 mandibular processes (B)

-2 maxillary processes(C)

*D: Pericardial Swelling

26-day embryo
The structures limiting the me rat ach
stomatodeum areclearly
recognizable

*A: Front View

*B: Side View
‘enya© 2003,Mosby ne Al ahs reserved
161|Page
27-day embryo
The beginning elements for facial development Frontal prominence
and the boundaries of the stomatodeum are Frontonasal process
apparent.

a
*In front view Fest cen “ey
Mandible

>The oropharyngeal (buccopharyngeal) membrane separates the oral cavity from

the pharynx
(which ruptures at the end of week 4)
-Bilaminar membrane: Frontal
1- Outer ectodermal layer prominence
2-Inner endodermal layer
*The membrane breaks down, leaving ‘Stomatodeum7 “ Ul cut
continuity between the ectodermally lined
oral cavity and the endodermally lined Cardiac
\ bulge
pharynx.
Buccopharyngeal
membrane nr0 yAme
This is a sagittal section

* The presenceof a buccopharyngeal membrane is a hallmark of a 4 weeks

intra-uterine life, and it disappears after 4 weeks

162 | Page
 Oral Embryo a
e 5th week in utero
> Nasal and optic placodesarise from thickening of the ectoderm.
*Optic placode: Marksthesite of future eye
*Nasal placode: Marks thesite of future nasal cavity
> Nasal placodes sink into the mesenchyme
forming 2 nasal pits.
Theydig deeperto form a depression and eventually
thecavity
> Proliferation of mesenchyme from the
frontonasal process around the openingsof the
nasal pits produces the medial and lateral nasal
processes.
(Lateral processis lateral and above, whereas
the medial processis medial and below) A: Optic placode E: Maxillary process
B: Nasalpit F: Mandibular process
C: Medial nasalprocess G: 2ndbranchialarch
D:Lateral nasal process

34-day embryo
Nasal pits have formed thereby delineating
the lateral and medial nasal processes. Frontal prominence
Medial nasal process
*In front view
a 4 tata process
Mandibular process,

163 |Page
 > When the nasal cavity is formed a membrane called the oronasal
membraneremains, which separates the primitive nasal and oral cavities.
The membrane rupturesby the end of week 5 to produce a communication
between the two ca

Note:
-Oropharyngeal membrane:separates oral cavity from the pharynx
-Oronasal membrane: Separates nasalandoral cavities

Oral Cavity een

feud COEca

PEN aend

164 | Page
 > Nasal fin: A sheetof epithelium in front of each nasal pit
> Maxillary isthmus:A bridge of mesenchyme thatjoins the maxillary and
medial nasal processes. (Which eventually forms the isthmus)

A: Nasal cavity
B: Oral cavity
C: Nasalfin
D: Oronasal membrane
E: Maxillary isthmus

So during the 5"* week in utero:

-Nasal placodes form

which sink into the mesenchyme forming:
-2 Nasal pits
which delineates the:
-Medial and lateral nasal pits
then
-Nasal cavity forms
then
-Oronasal membrane,nasal fin and maxillary isthmus form

165 | Page
 © 6th week utero

>The 2 mandibular processes fuse forming the lower jaw.

Maxillary and mandibular processes meetat the angle of the mouth. (Lateral
fusion)
>From those corners, maxillary processes grow inwards beneath the lateral
nasal processes towards the medial nasal processes. (Maxillary processes
spread out anteriorly to meet with the medial and lateral nasal processes to
close the gap where a grooveis seen at the site where thy meet)

A: Mandibular
process
B: Maxillary process
C: Lateral nasal
process
D: Medial nasal
process
E: Naso-optic furrow

Grooves are namedas the following:

1- Between the maxillary and naso-lateral processes: Naso-optic furrow or
nasolacrimal groove (because it is the site where tear ducts form)
*From each furrow an ectodermal rod ofcells sinks below the surface and
canalises to form the nasolacrimal duct.
2- Between the maxillary and naso-medial processes: Bucconasal groove

166 | Page
 *The following table is very important

Pharyngee! Muscular contibutions") Skeletal contibutions Nerve Artery

ae maxilla, mandible (only as a model
Ast (also called anterior belly af digastic for mandible not actual formation of Trigeminal nene
"mandibular eeee em = mandible), the incus and malleus of (V2 and V3) Maxillary artery
arch’) tenswionyor’,
or vei palatni tympan!, the middle ear,also Meckels
caritage
Muscles offail expression, a.sivod process,hyo
2nd (also called |buccinatr,platysma, (lesser horand upper Part of Body), |Facial nerve (Vl) Stapedial Artery
‘the “hyoid arch’)|stapedius,stylohyoid,
Roe digastric Reicher's cartilage
3d
Hyoid (greater hom and lowerPart of |Glossopharyngeal Common caratid/nternal
Styophayngeus Body) nerve (X) carotid
thyroid cartilage, epiglattic Vagus nerve (X) Right right subclavian
4th ininsic muscles of so palate |ioe a layrgeal sreLed soi ach

Vagus nerve (x) "a ht right pulmonary

intinsc muscles ofl[id catlage, antenid cages, peeranges ateUtet SPulmonry
comiculate cartilage! renal’ artery and ductus
arteriosus

- Pharyngeal arch: Lateral swellings around the pharynx in the embryo,and it

has 6 derivatives.
Each oneofthese derivatives has its own muscular and skeletal contributions,
nervesand arterial blood supply.
- The First derivative is also called the mandibular archand it’s divided into 2
parts : maxillary process and mandibularprocess.
- For the skeletal contributions, the maxilla originates from the maxillary
process and the mandible originates from the mandibular process.

167 | Page
-The maxilla consists of 2 parts:
1- Pre-maxilla that holds the incisors (originates from the medial nasal
process)
2- Maxilla proper that holds the canines and the posterior teeth (originates
from the maxillary process)
*Skeletal contributions usually mean cartilage and bone.

- Nerve supply has 2 branches (V2 and V3):

V2is the maxillary branch and V3 is the mandibular branch.
*V is the Latin number 5.
And the fifth cranial nerveis called the: Trigeminal nerve
-The ear is composed of 3 bones which are:
1- Incus
Origin: Cartilage of the maxillary process ofthe first arch.
2- Malleus
Origin: Meckel’s cartilage of the mandibular process ofthe first arch.
3- Stapes
Origin: Reichert’s cartilage of the second arch which is called the hyoid
arch.

*All other details have to be memorized from thetable.

168 | Page
« 7th weekin utero

a wa Lateral nasal process

Dissecting
microscope B Medial nasal process
imageof a
hi Groove separating the maxillary
abeye t processfrom thelateral nasal
embryoat process(naso-optic groove)
7 weeks
) Maxillary process
Groove separating the maxillary
process from the medial nasal
process (bucconasalgroove)

Copyright © 2003, Mosby, Inc.,All rights reserved.

169 |Page
 Upperlip development

*No theories are made yetfor the development of the lower lip
Twodifferent theories:
1- Maxillary processes outgrow the medial nasal processes and meetin the
midline.
2- Maxillary processes meet the medial nasal processes, thus the middle third
ofthe lip is derived from the frontonasal process

* The more relevanttheory, which says that the middle region ofthe lip-the
philtrum- is derived from the meeting ofthe right and left medial nasal
processes. So, they make up the middle region of the upper lip and the
middle region of the nose.)

Lateral nasalprocess
Maxillary process
Medial nasalprocess

Mandibular process

*The lateral nasal process contributesto the sides of the nose, but it has no
relation to the lip. The rest ofthe lip originates from the maxillary process

170|P age
Developmentof the palate

6th week in utero

> During the 6" week ofintrauterine life, the nasal cavities are separated by
a nasal septum. ( also called primary nasal septum, because it lies above the
primary palate)
>The nasal cavities are separated from the oral cavity by the primary
palate.

* The palate is composed of2 parts; primary palate and secondary

palate.
The primary palate-anterior region- is considered a part of the pre-
maxilla (the region that holds the incisors).
* The hardpalate is supported by bonesand the soft palate is supported
by muscles.
>The nasal septum and the primarypalate are derivatives of the frontonasal
process. ( morespecifically the medial nasal process.

A: Primary nasalcavities
B: Primary nasal septum
C: Primary palate

a7i|Page
Twolateral palatal shelves develop behind
the primary palate.
The lateral palatal shelves are derived from the
maxillary processes
>The secondary nasal septum develops
behind the primary septum

A: Lateralpalatal shelves
B: Primary palate
C: Secondary nasal septum

7th weekin utero

the developing tongue.

Palatal shelves keep on growing till theylie

vertically.

Secondarypalate begins to develop via the

lateral palatal shelves which are growing vertically, A:Lateralpalatal shelves
becausethe size of the tongue is large in regard to B: Developing tongue
the oral cavity (where it completely fills the cavity at
this stage), therefor the palatal shelves cannot grow
horizontally.
*But by the 8'" week,the size of the oral cavity
becomeslarger, and the tongue goes down, so the
lateral palatal shelves begin to growhorizontally.

172|Page
8th week in utero
>The stomodeum enlarges.
Nasal
septum

7*week Coronal sections through human embryos 8” week

>The tongue dropsdue to a change in shape and mandibular growth.

The palatal shelves become horizontal and contact each other. Their
contact forms the secondary palate.

173 |Page
 8-12 weeksin utero
>The secondary palate contacts the primary palate to divide the nasal
cavity from the oral cavity.
- So by the end of the 8" week, the palatal shelves make an initial contact.
- During the 9" week,full contact is completed.
- During the 12" week,fusion is
completed.

Behind the secondary nasal septum,

the shelvesfuse to form thesoft
palate and the uvula.

A: Palatal shelves
B: Secondary nasal septum
C: Midlineepithelial seam
D: Developing maxillary bone

The epithelium at the medial edges of the palatal shelves fuse together to
form the epithelial seam (A).
>The seam disintegrates to allow mesenchymal continuity across the
secondary palate.

174|Page
 Ossification of the hard palate starts once the fusion of the palatal shelves
is complete.
>Intramembranousossification from four centres.
- One in each developing maxilla.
- One in each palatine bone
*Intramembranous ossification: Process of bone development from fibrous
membranes (mesenchyme tobone), and it occursin maxillary and palatine
bones.
Unlike Endochondral ossification wherecartilage is replaced with bone.

Nasal Cavity

Developing body of
the maxilla

jone extending
to the palate

175 |Page
 > Coronal sections through human embryosat approximately
(A) 7 weeks (initial disposition of palatine shelves on eachside of the
tongue)
(B) 8 weeks (elevation coincident with depression of the tongue)
(C) 9 weeks (full contact

176 |Page
Developmentof the Mandible

The mandible develops initially intramembranously, beginning at the mental

foramen, but subsequent growth depends on the appearance of secondary
cartilages.
The body, alveolar bone (surrounding the roots) and the angle areall formed
by intramembranousossification. (Primary ossification centers, week 7)

*The coronoid process, condyle and mandibular symphysis are all formed by
endochondral ossification. (Secondary ossification centers)
Meckel’s cartilage is a rod of carilage that develops from the first branchial
arch (6 weeksin utero).
It extends from the developing ear to
the midline (region of mandibular
symphysis). Acts as a framework for
the bone formation.
So it supports the mandibular
processofthefirst pharyngeal arch
until enough amountofboneis
formed. This cartilage doesn’t turn
into mandibular bone ( the
mandibular bone is formedby intra
membranousossification except for
the regions mentioned above)

177 |Page
- Meckel’s cartilage is considered a primary cartilage, becauseit is formedprior
to bone formation (bone formation begins at week 7).
Whereas, secondary cartilage centers are formedafter the bone is formed.

-When the mandibular bone starts to form, this cartilage starts to decrease in
size gradually (resorption until it disappears) excepta part ofit, the most
posterior region, which then turns into one ofthe bonesof the middle ear,
malleus

The mandible developsas a dense fibrous tissue band on the anterolateral

aspect of Meckel’s cartilage.
A centreofossification appearsin the fibrous tissue near the future mental
foramen (7 weeksin utero). t iW 1%
eff
Bone formation spreads backwards, forwards and f
upwards.

1
A: Meckel’s cartilage

B: Dentallamina

C: Tongue
\
D: Neurovascular bundle \

178 |Page
-Formation of a plate of bone lateral to the cartilage (future body of the
mandible).
-Plates on bothsides do not meet and are
separated by fibrous tissue thus forming the
midline symphysis.

A: Meckel’s cartilage
B: Bone
C: Tongue
D: Midline symphysis

- Continued bone formation leads to an increasein the size of the

mandible.(Bone increases, meckel’s cartilage decreases)
- Formation of the alveolar process around the developing tooth buds.
(Alveolar bonesstart to form from parts of the tooth germ and then is
connected to the body of the mandible)

-Neurovascular bundle starts to be surrounded by

bone.
(Neurovascular bundle is composedofinferio-
alveolar nerve,inferio- alveolar vein and inferio-
alveolar artery)
A: Alveolar process
B: Neurovascular
bundle

C: Meckel’scartilage

D:Tongue
179 |Page
-Meckel’s cartilage resorbs.
-The neurovascular bundle becomes contained within a
bonycanal.
-The mostdorsal part of meckel’s cartilage ossifies to
form theear ossicles. (This is only true for one of the ear
ossicles, the malleus, because that’s what Meckel’s
cartilage contributes in.)
-The perichondrium ofthe cartilage forms ligaments.
(Specifically, the sphenomandibular ligament, between
the sphenoid bone and the mandible.)

B: Neurovascular
bundle
C: Tongue
-Alveolar bone forms around developing tooth germs.
(Alveolar bone is considered a part of the development of the tooth germs.)
-Bone resorption on the inner wall c~
(Howship’s lacunae).
-Bone deposition on the outer wall
(osteoblasts and osteoid).
-Interdental septa.

(The alveolar bone between adjacent

teeth)
-Inter-radicular bone A Mandibularalveolus
(The alveolar bone between the rootsof the same tooth.) B Developing tooth
(Only in posterior teeth as they are multi-rooted, © Howship’s lacunae
whereasanterior teeth are mostly single-rooted) D Osteoblasts

180|Page
-The ramus of the mandible develops as a fibro-cellular condensation.
(means intramembranous condensation). Continuous with the body of the
mandible.
-Backwards spread ofossification.
-Appearance of3 secondary cartilages (10-14 weeks in utero).
(Same stage as whenthe fusion ofthe palate is completed)
-The condylar cartilage is the main one, and there are other cartilages
associated with the coronoid processes and in the region of the mandibular
symphysis.

‘Copyright© 2003, Mosby, Inc., All rights reserved.

Articular
eminence

Synovial
Articular| cavity
disc

181 |Page
 Oral Embryo
-The condylar cartilage appears beneath the fibrous
articular layer of the future condyle.
-The temporomandibular joint develops from
mesenchyme between the temporal bone and the
developing condyle.
-The upper and lower joint cavities appear as clefts
during the 12th week in utero.
-Remaining mesenchyme becomes the articular
disc.(The disc in the middle ofthe joint)
- Joint capsule.

A: Condylarcartilage
B: Meckel’s cartilage
C: Boneofthe mandibular
fossa
D: Developingarticulardisc
*Here, the condylar process is present in
the form ofcartilage (condylar cartilage), which will be replaced by bone later.
-The ramus of mandible becomes morevertical in adults, whereas at birth and at
childhood (6 years ofage) it is more posteriorly inclined.

Adult 6 years of age At birth

Developmentof the Maxilla

Med. palp. lig.

Alveolar canals
Maxillary tuberosity

VeloCaries
wit. “Promaiars

-The maxilla develops intramembranously with the centre of ossification

appearing during the 8" week of intrauterine life.
-Growthis affected by the developmentofthe orbital, nasal and oral cavities.
-Different processes: palatine, zygomatic, frontal and alveolar.

A:Developing maxilla
B: Developing canine
C: Palatine process
183 | Page
 -The maxilla grows by bone remodelling and suture growth.

- Eyeballs, nasal septum and orbital pad of fat provide forces that separate
the maxilla from adjacent bones,thus allowing sutural growth. (sutural
growth means that there are forces that prevent the blending to allow for
more growth)
-An outpocketing of the middle meatus of the nose results in the appearance
ofthe maxillary sinus (4 months in utero).
(maxillary sinus is the paranasal sinus)

*In the intrauterine life, a month = 4 weeks, so that means 16 weekshere.

L
\ Roof
Medial
wall \ Lateral wall
Floor

A W

Roof
Anterior — Posterior wall
wall A: Front view
— Floor
B: Side view
8

184|Page
Developmentof the Tongue

The tongue developsfrom different embryological origins.

-The anterior 2 thirds is derived from 3 swellings:

+ 2 lateral lingual swellings

* 1 midline tuberculum impar

-The posterior third is derived from a single midline swelling called the
copula.

-The lateral lingual swellings and the tuberculum impar are proliferations of
the mesenchyme beneath the oral epithelial lining of the 1st branchial arch.
* The lateral lingual swellings and the tuberculum impar form the anterior
2 thirds
* The copula forms the posterior one third.

-Innervation from the facial nerve (2nd arch), in addition to the nervesof the
1st, 3rd and 4th arches.

* The anterior 2 thirds is mainly formed from the first arch, with a minor
contribution from the second arch. So,the general sensation of the anterior
2 thirds is provided bythe trigeminal nerve(the nerve ofthe first arch). But
the taste sensation is provided bythe facial nerve (the nerveof the second
arch).

* The copula is mainly from the 3rd branchial arch with a contribution from
the 4th. (The posterior onethird is derived from the 3rd arch because the
copula is derived mostly from the 3rd arch. So, the majority of the posterior
one thirdis derived from the 3rd arch, which means the general and taste
sensations are supplied by the glossophalyngeal nerve (the nerve of the 3rd
arch).
185 |Page
 *Excepta part ofit, the end of the copula originates from the 4" arch. The
mostposterior part of the copula and the epiglottis originate from the 4th arch,
which means their general and taste sensations are supplied by the vagus nerve.
(the nerve ofthe 4th arch)

A: Laterallingual swellings
B: Tuberculum impar
C: Copula

- Tongue muscles develop from occipital somites that migrate into the tongue
with their nerve supply (hypoglossal nerve).
(Occipital somites: swellings on the sides of the
spinal cord)
- The thyroid gland develops between the
tuberculum impar and the copula. (there’s an
opening between the tuberculum impar and the
copula, which is called foramen caecum.

In the embryo,this foramen is the beginning of a

duct (thyroglossal duct, between the tongue and the thyroid gland), so the
thyroid gland is originated from the end of this foramen. When the thyroid
gland is formed,this ductis resorbed, so that there isn’t any connection left
between the tongue and the thyroid gland.
* But there are remnantsof this duct, a simple depression, called the foramen
caecum.

186 | Page
- Foramen caecum on the fully developed tongue. (the foramen caecum is
remnantsof the thyroglossal duct on the fully developed tongue)

-The circumvillate papillae is present in front of the sulcus terminalis.

Theyare considereda part ofthe posterior one third of the tongue because
they have the same origin in embryo,they arise from the posterior one third.

-Anatomically, they are present in the anterior 2 thirds of the tongue. The nerve
supply always follows the embryonic origin . So, the nerve supply hereis the
glossopharyngeal nerve.

. Tongue
ce
Copyright © 2003, Mosby,Inc., All rights reserved.
Sagittal sections through human embryos

187 | Page
 Clinical Considerations
Failure of fusion of the facial processesresults in several variationsoffacial
clefts

I co \

A: Median cleft lip (upper at the midline,failure of fusion between the right
and left medial nasal processes.

B: Bilateral cleft lip (if it’s only on one side,it’s called unilateral cleft lip).
Failure of fusion between the medial nasal process and the maxillary nasal
process.
C: Oblique facial cleft (failure of fusion of the maxillary process and both of
the lateral and medial nasal processes. It originates from the eye, and reaches
the oral cavity.)

D: Lateral facial cleft (failure of fusion between the maxillary and mandibular
processeslaterally. And sometimesit’s called macrostomia because the oral
cavity is enlargedin this case.)

E: Median mandibular cleft (failure of fusion between the two mandibular

processes)

188 | Page
Unilateral cleft lip, with a palate cleft (when thereis a
failure of fusion between 2 lateral palatal shelves.) Bilateralcleft lip with a palate cleft

Bilateralcleft lip with a palate Thisis the simplest typeof a palatecleft,

cleft. whichis called bifid uvula. The fusionofthe
The cleft region usually has hard palate and the fusion ofthesoft palate
missing teeth, and most are found, but the fusionof the uvula at the
commonlyit the lateral end ofthe soft palate isn’t. (partial failure of
incisor which is missing. fusion betweenthe2 lateralpalatal shelvesin
theposterior region.)

189 | Page
Retention of epithelial remnants in the palatine midline mightlead to the
formation of a midline palatine cyst.

The midline epithelial seam separatesthe 2 lateral palatal shelves and

disintegration occurs, remnantsofthis line are called rest cells or dormant
cells. These cells might remain dormant
throughout life or they might be activated i s
for unknown reasons forming cysts. This aoe ‘¢
cyst that was formedin this region is called 5.
a midline palatine cyst. i ©

190|Page
 Early tooth development iff@)

Outline
1- Tooth development phases:
= Initiation
= Morphogenesis
= Histogenesis
2- Stages of tooth germ formation
= Bud stage
= Cap stage
= Early bell stage
= Late bell stage
3- Transitory structures
= Enamel knot
= Enamel cord
= Enamel niche
4- Root formation
5- Epithelial mesenchymal interaction (excluded)
6- Clinical considerations

agi] Page
 Periodontium 1

1- Tooth developmentphases
1- Initiation
This phase is represented by the Primary epithelial band stage which occurs
at the 6" week.
- In this phase,the locations of teeth are established with the appearance
of tooth germs.
- Tooth germs appear along the dental lamina (an invagination in the oral
mucosa).
- When the thickening ofthe oral ectodermis the beginning of this phase,
which marksthe site of future tooth development.
- This involves interaction between the epithelium and the underlying
ectomesenchyme,because ofthat it’s called epithelial-mesenchymal
interaction stage.

2- Morphogenesis
- Morph means shape,so the shape ofthe teeth is determined in this
phase.
- Cell proliferation and movement determine the shapes of teeth.

3- Histogenesis
- Differentiation of cells takes place to produce the fully formed dental
tissues. (Like for enamelformation we needdifferentiation of cells to form
ameloblasts, or dentine we need odontoblasts, or for cementum we need
cementoblats..
- Histogenesis begins during morphogenesisas all the phases are
overlapping. (Which meanshistogenesis begins even though the
morphogenesis is not completed yet. So this process occurs area by area,
for examplethe cusp orthe incisal edge areas precedeotherareas in
formation, so after morphogenesis histogenesis begins in the cusp area
while the cervicalareastill in the morphogenesis stage).
192 | Page
 Periodontium 1

Tooth development

- Inthe primitive oral cavity, mesenchymal condensation underneath the

dental epithelium takesplace.
Ectomesenchymal in origin (migrated from the margins of the neural tube).
Importantnote: the Interaction between oral ectoderm & underlying
ectomesenchyme,and whyit’s called ectomesenchyme not mesenchmyme
alone?
It’s called Ecto because it is originated from neural crest cells, which comes
from a special region between the neural & non-neural ectoderm.
Between these 2 areas in the border thereis the neural crest; the cells
originated from there undergoesepithelial mesenchymal transformation, so
the epithelial cells become mesenchymal cells which has the ability to migrate
to variety of regions in the body including these ectomesenchyme cells.
Note: ectoderm is composedof 2 areas; neural (from which the nervous
system arises) & non-neural (whichgives the remaining of the body).

- Role of endoderm?
It’s thought to have NO role in tooth development, but may have a role ONLY
in third molars development as they come most posteriorly. Otherwise all
teeth formed by ectoderm & underlying ectomesenchyme.

193 | Page
gf jodontium 1

Events in 6 weeks in utero

- Thickeningofthe oral epithelium.
- Invagination of the epithelium into the mesenchyme to form the primary
epithelial band(initiation stage).
So the hallmark ofthis stage is thickening of the epithelium.

Maxillary
process

Mandibular
process
Developing tongue

194 | Page
 Periodontium 1

Eventsin 7weeksin utero

The primary epithelial bands divide into:
= Vestibular lamina (buccally).
= Dental lamina (lingually).

- The vestibular lamina contributes to the

development ofthe vestibule.
- Vestibules delineate the lips and cheeks from the tooth bearing regions.
- The dental laminacontributes to the formationof the teeth.
- Degeneration ofthe central epithelial cells producing a sulcus.
Y So the vestibule starts as solid sheath of epithelium then > central
degenerationofcells occur to form the vestibule.
- For staging we look at the end of the dental lamina, so for example:
If the lamina is straight, doesn’t have a particular shape, then this indicate
7" week stage.

-_ If the end looks oval then > 8'" week.

- If it looks like a cap, then:
If part of the cap is straight then > early cap stage, 11" week.
If part of it looks curved then > late cap stage, 12'" week.

195 | Page
 Periodontium 1

© Events in 8weekin utero (bud stage)

Swellings develop on the deep surface of the =
dental lamina.
Each swelling is surrounded by a
mesenchymal condensation.
Swelling = tooth bud.

Ectomesenchym al
condensation

2- Stages of tooth germ formation

Tooth germs are classified into different stages (bud, cap, early and late
bell stages).
This is only for descriptive purposes.
Odontogenesis is a continuous procedure without definite stops. (Which
meansthereis always an intermediate stage. And there are noclearlimits
between every two successive stages).

1- Bud stage
The enamel organ appearsas a simple ovoid epithelial mass. (As /ater on it
will be responsible of enamel formation).
Surrounded by mesenchyme.
Mesenchyme separated from the epithelium by a basement membrane.

196 | Page
 Periodontium 1

(Always betweenepithelium & mesenchyme there is a basement

membrane,like between epithelium & lamina propria).

Ectomesenchymal
condensation

2-Cap stage
= 11 weeksin utero (early cap)
- Morphogenesis progresses.
- Invagination of the deeper surface of the enamel organ.
- Peripheral cells start to be arranged as external cuboidal and internal
columnar enamel epithelium.
- Central cells more rounded. Later on they will take star shape and be called
stellate reticulum.

197 | Page
 Periodontium 1

= 12 weeksin utero (late cap)

- Central cells in the enamel organ become separated (stellate reticulum).
- Cuboidal external enamel epithelial cells.
- Columnar internal enamel epithelial cells.
- Proliferation of the surrounding mesenchyme.
- With the clear formation of the cap shape the mesenchyme lying beneath
the internal enamel epithelium will be clearer and called Dental papilla.
- The rest of the mesenchyme surrounding the tooth germ forms the Dental
follicle.
v Enamelorgan + dental papilla + dental follicle = tooth germ

lucked
fey cy
Wecan see that it
(lolaRu ecole)
Bra

198 | Page
 Periodontium 1

3- Early bell stage 14 week in utero

The shape of the internal enamel epithelium decides the shape of the
crown.
Mitotic activity at different sites affects the folding. Also the balance
betweenthe hydrostatic pressurein the stellate reticulum and the blood
pressure in the dentalpapilla(as it is an ectomesenchyme whichis
vascularized) has an effect on the crown shape, any imbalance between
them wouldcauseinvagination or evagination which wouldaffect the
shape.
Note: the stellate reticulum whichis inside the dental organis avascular.
Contribution of available space and mechanical forces.
The Dental lamina breaks the remnantsofit are called Epithelial rests of
serrez.

Dental follicle in this stage differentiate into 3 layers:

Inner vascular fibrocellular condensation.
Loose connective tissue layer.
Outer vascular layer lining the alveolus.
The inner & the outer layer are highly cellular & highly vascularized, while
the middle is less vascular & less cellular.
= Theselayerslater on will form these tissues:
Inner layer > cementum.
Middle layer > periodontal ligament.
Outer layer > alveolar bone.
Dental papilla > dentine & pulp.
Enamel organs > enamel.

199 | P ge
 Periodontium 1

- Four distinct layers in the enamel organ:

1- External enamel epithelium.
2- Stellate reticulum.
3- Stratum intermedium.
4- Internal enamel epithelium.
(Beforethis stage it was composed of3 layers;
inner, outer and stellate reticulum).
v Stratum intermedium: twoor three layers of
flat cells which separates stellate reticulum &
internal enamel epithelium.

“+ External enamelepithelium
- The outer enamel epithelium forms the outer layer ofcells in the enamel
organ.
- Cuboidal or flat cells.
- Abasement membrane separates the cells from the mesenchyme of the
Dental follicle. (particularly the inner investing layer of the dental follicle
- Large central nuclei).
- Small amount of organelles related to protein synthesis.
- Desmosomes and gap junctions.

200| Page
 Periodontium 1

* Cervical loop
- The cervical loop is at the growing
margin of the enamel organ.
- Lies at the junction between the
inner and outer enamel epithelium.
- High metabolic activity.

“Thestellate reticulum
- Intercellular spaces become fluid filled.
- Star shaped cells with branching processes.
- Prominent nuclei,little endoplasmic reticulum and few mitochondria.
- Developed golgi apparatus and microvilli suggest a role in extracellular
material secretion.
- They contain Glycosaminoglycans,alkaline
phosphatase.
- Mesenchyme like features; like the ability of
synthesis ofcollagen.
- The stellate reticulum protects the underlying
tissues and maintains the tooth shape by
- Balance between the hydrostatic pressure of the
stellate and the papilla. Which effect on crown
outline.

201| Page
 Periodontium 1

“Stratum intermedium
The stratum intermedium consists of 2-3 layers of
flat cells.
Lies over the internal enamel epithelium.
Resemblesstellate cells but with smaller spaces. (So
it’s condensedover the enamel epithelium).
It has variety of functions:
1- Stem cells for replacement of internal epithelium
cells.
2- Transport ofnutrients & waste products to &
from the internal layer.
3- Concerned with protein synthesis.
4- Concentrates materials.

The internal enamel epithelium

The Internal enamel epithelial cells are columnar.
Rich in RNA and contain NO alkaline phosphatase.
Separated from the dental papilla by a basement membrane and a cell
free zone.

* The dental papilla

- During the early bell stage they appear as:
* Closely packed mesenchymal cells.
= Few fibrils.
= Rich in glycosaminoglycans.
- Part of these cells near the internal enamel epithelium will differentiate
into odontoblasts which will secrete dentine.

202 | Page
 Pe dontium 1
4-Late bell stage (begins at 18th weekin utero)
- It begins at 18th week in utero and continues.
- Weidentify it as 18" week if the secretion has just starts in the cusp or
incisal edge areas, and wefind only dentine not enamel.

- The pic beside shows secreted dentine & enamel, telling that
it is definitely older than 18 weeks.
San ReeRC etea oo) toe

MCR Rede Deneenau atheree se

RecentReenaeoUP EI
OPARace Onurennaei ateau
ENIEn
LTMueeaeaee
OeaeSaeedae

- Lingual down growths of the external enamel epithelium give rise to the
permanentanterior teeth buds (5 months in utero). (Which means the
successional lamina reaches the bud stage at week 20 = 5 months).
In embryo 1 month = 4 weeks.

- Dental lamina growsposteriorly to give rise to the tooth buds of

permanentposterior teeth (4 months in utero = 16 weeks).
- Other namesoflate bell stage are: advancedbell stage, crownstage,
appositional bell stage.

- Appositional stage; formation of dental hard tissues.

203 | Page
 Periodontium 1

Dentine always precedes enamel. (Thefirst layer secreted of dentine &

enamelis the closest to the dentino-enameljunction).
Hard tissues formation starts at the cusp tips or incisal edge.
(If the tooth has more than one cuspthen the largest oneis the first in
hardtissue formation then the smaller andso on..., for example maxillary
molarsthe first is mesiolingual then mesiobuccal, then DB, then DL. Other
example mandibular molars, the first is ML then MB then DL then DB &
finally the distal cusp).

= The following represent the arrangement ofsteps in dentine &

enamel formation:
1- Internal enamel epithelial cells differentiate into pre-ameloblasts.
2- Pre-ameloblasts induce adjacent mesenchymal cells to differentiate
into odontoblasts.
3- Odontoblasts produce pre-dentine and dentine.
4- The presenceof dentine induces ameloblasts to form enamel.
v Remember:the origin of ameloblasts & odontoblastsis internal
enamel epithelium.

In the pics we can notice the

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204| Page
 Periodontium 1

Re eaReeaCr
CET HOR Mem eee eR C1 ae)
OlePar PR el Aae rg
Orca eee eStart
Ne Teer Rue
MEE CS eMeet eteaT
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- The beginning ofthe late bell stage represents the first evidence of
calcification.
And whenthe secretion reachesthe surface this represents the crown
completion.
(Wecan estimate the age by the amount of secretion but we are not
concernedwithit).

205 | Page
 Periodontium 1

3-Transitory structures
= Enamel knot
= Enamelcord
= Enamel niche

1-Enamel knot
In the early & late cap stage, a condensation ofcells starts to appear, part
ofit from enamel epithelium & the other from stellate reticulum which
appearslike central cluster.
Localized massofcells in the center of the internal enamel epithelium.
May bulgesinto the dental papilla.
Non proliferative cells.
Determine location of future cusptip/ incisal edge area. Depending on the
numberofknots wecan predict the numberof cusps, if we have 3 knots
thenthe tooth would have 3 cusps, if one then the tooth would have an
incisal edge...
Signalling centre; BMP, FGF, Shh, transcription factors.
BMP = bone morphogenetic proteins, FGF = fibroblastic growthfactors,
Shh = sonic hedgehog.

206 | Page
 Periodontium 1
2-Enamel cord
- Astrand ofcells extending from the stratum
intermedium into the stellate reticulum. Soit is a
meeting point betweenthe outer & the inner enamel
epithelium passingin the stellate reticulum.
- The enamel septum (A):
an enamel cord that completely splits the stellate
reticulum.
Note: Some referencesdifferentiate between enamel
cord & septum butfor us it doesn’t matter and wewill
consider them the same.

- The enamel navel (B):

the invagination where the enamel cord meets the external enamel
epithelium.
- It is a Mechanical tie and Focus for stellate cells formation. So they are
stem cells for replacement ofstellate reticulum.

3-Enamel niche
- It’s not considered an original part of the tooth germs,but it’s an
ectomesenchyme between the multiple attachments. Usually the tooth
germ has one attachment which is the primary dental lamina.
- Anarea enclosed between 2
septa that form a double
attachment to the dental lamina.
- Funnel shaped depression
containing connective tissue.
Whichis the ectomesenchyme.

207| Page
 Periodontium 1

4- Root formation
- Whenenameland dentine formation are well MG
advanced (atleast it reached half of the crown), |), 4/
the enamel epithelia at the cervical loop forms hi ua
double layered root sheath which is called
Hertwig’s root sheath (formedby only inner &
outer enamelepithelium without the remaining
layers stratum intermedium stellate reticulum).
No stellate reticulum.
Proliferates apically.
Outlines the shape of the root.
Epithelial shelves grow to demarcatethe location
of multiple roots. (The growth starts verticallyif it
starts to grow horizontally then this is called
epithelial diaphragm which determine
eteaura Ra ea ad
the location offurcation in multirooted teeth).
rootsheath creates a
This Hertwig’s of epithelial root sheath is
eteem Ureecru
responsible of everything related to the root Cone ree ante
including the shape, number & length of the roots esa
Cees
The dental follicle (sac) forms cementum,
periodontal ligament and alveolar bone.
Arrangement of tooth formation events:
Y Differentiation of odontoblasts induced by inner layer of the sheath
which later on will form the predentine >
Vv Then calcification occur forming dentine which leads to disintegration
of the Hertwig’s epithelial sheath and formation of pores >
Y Sotherewill be connection between inner investing layer of the
dental follicle and the newly secreted dentine >

208 | P ge
 Periodontium 1
This will inducecells of the inner investing layer (mesenchymal cells) to
differentiate into cementoblasts to secrete cementum.
In this level the hyaline layer had been already formed by the Hertwig’s
root sheath,so all root layers (dentine, hyaline and cementum) are
formed.
- The remnants of the Hertwig’s root sheath after dentine formation is
called epithelial rests of Malassez.

** Nerve fibres and blood supply

- Nerve fibres form a plexus below the dental papilla at the cap stage.
- Diffusion into the dental papilla and follicle.
- 2 types of nerve supply: Autonomic and sensory.
- Small blood vessels penetrate thepapilla at the early bell stage.
- Apparentin the follicle adjacent to the external enamel epithelium.
- Blood vessels do not penetrate the enamel organ. Asit is considered
epithelium whichis avascular.

” Differentiation
- The dental papilla is the dominant tissue in both morpho- and histo
differentiation.
- Many experiments proved this dominance.
v These two points means: theidea is the tissue that determine the
shape of the toothis it the ectomesenchyme or ectoderm?
For example: if we take an ectoderm from place where should an
anterior tooth develop and placeit in ectomesenchyme where should
posterior tooth develop, what is the tooth that would form, anterior
orposterior?
The scientists found that that ectomesenchyme dominate, so the
tooth developed wouldbe posterior one.

209 | Page
 Periodontium 1

5- Clinical consideration
= Congenital tooth abnormalities.

= Induction problems.

= Splitting or fusion of tooth germs.

Splitting (gemination): when the tooth germ splits and form two (Sass
teeth instead of one. COEUR
Fusion: 2 tooth germs fuse to form one tooth instead of one. Caled
Splitting & fusion are called twinning.

= Malformations in shape, size, number orstructure.

= Macrodontia (large teeth) and microdontia (small teeth), it may be localized

or generalized. Examples:
-Generalized microdontia in pituitary dwarfism (which results from deficiency in
growth hormonefrom thepituitary gland).
-Generalized macrodontia in pituitary gigantism (result from over secretion of
growth hormone).

= Peg shapedlaterals,it’s an example of abnormalities in teeth shape, it

doesn’t have an incisal edge instead it has appointed cusp.

= Double tooth; gemination or fusion.

= Concrescence. It’s like fusion but in roots ONLY without crowns, so the fusion
is partial and happens between 2 different teeth like central & lateral.

210 | Page
 Periodontium 1

= Odontomes. Wehave types: evaginated & invaginated.

- Invaginated odontomes (or dense in dent):
o Appear as enamel invaginated (entering) the pulp. It happens
when hydrostatic pressurein stellate reticulum exceeds the blood
pressure in dental papilla. Which results in hard tissue formation
(enamel & may bedentine) in the pulp tissue. Commonly it’s
foundin the lateral teeth. (Dense in dent meanstoothinside the
tooth).
© _Exaggeration of the cingulum pit formation.
o Retarded growthofpart of the tooth germ.
o Active proliferation of an area of the enamel organ into the
dental papilla.
© Displacement of part of the enamel organ into the dental papilla.

2 Page
 Periodontium 1
- Evaginated odontome:
Happens when the bloodpressure in dental papilla exceeds the
hydrostatic pressurein stellate reticulum, so the internal enamel
epithelium evaginateto the outside
(Also called “dense evaginatus” or “premolar odontome”or “lenog
premolar”) as it happens most commonly in premolar: _

= Defects in numberof teeth

1- Oligodontia, case represented by missing of 5 teeth or more. (also called
partial anodontia).
2- Hypodontia (partial anodontia), case represented bylose of less than 5
teeth.
Y Note: in these two cases the 3molar is excluded in counting asit’s
commonly missing.
3- Complete /true Anodontia; this patient doesn’t have teeth (it’s caused by
genetic defect e.g. ectodermal dysplasia; this disease has degrees soit just
causes complete anodontia in extreme cases).
Extra info: this disease also effects hair which causeshair lose, and the sweat
glands which resultin dry skin.

22| Page
 Periodontium 1

= Enamel pearls
- Small droplet of enamel on the root, near the furcation.
- Budding of Hertwig’s root Sheath and Differentiation of ameloblasts.
This case happens whenthe twolayers of the Hertwig’s root sheath
forming a placethat isfilled with stellate reticulum & stratum
intermediate, which meansforming of enamel organ whichwill form
enamel.
- It’s asymptomatic and discovered coincidentally.

ee

214 | Page
 Salivary Glands [El
Lecture Outline:
1- General organization.
2- Functions ofsaliva.
3- Methodsofsalivary secretion.
4- The parotid glands.
5- The submandibular gland.
6- The sublingual gland
7- Minor salivary glands
8- Clinical considerations.

1-GeneralOrganization:
¢ Salivary glands are compound tubuloacinar, merocrine, exocrine glands.

Whatdo we mean by “compound”,“tubuloacinar”, “merocrine”, and

“exocrine”?

© Compound: wehave more than one tubule entering the main duct, so the
duct system of the gland is branched (ex: all salivary glands)
© Simple: the opposite of compound (ex: sweat
glands).
© Tubuloacinar: a term used to describe the
morphologyofthesecretingcells (the secretory end
pieces that makethe secretions) , where some of
them are tubular (look like tubes) and others are
acinar (spherical in shape).

215 | Pag
7 Salivary Glands
© Merocrine: means only the secretion ofthe cell is released, so the cell
doesn’t loose anything except the secreted material
© Exocrine: describes a gland that secretesfluid to a free surface.
© endocrine: The opposite of exocrine, where the secretions go to the blood

> related
1-epocrine (like in mammaryglands): where the secretorycells lose some part
of the plasma membrane alongside the secretions

2-holocrine: the whole secretory cell is lost with its secretions (like in sebaceous
glands that are associated with hair follicles)

this pictureis from theinternet, andis usedforclarification only

216 | Pag
 Salivary Glands Z
eccf
capsule |
Salivary glands have 2 main components:
1. Glandular secretorytissue (parenchyma)

2. Supporting connective tissue (stroma)

The supporting stroma includes the capsule (all I

around the gland) .

From the stroma of the capsule, septa extend and \

divide the gland into major lobes, whichare further \
divided into loblules by smaller septa.

Lobescontain secretory units which contain acini

positioned around a lumen.

Acini empty into intercalated ducts, which join to

form striated ducts which emptyinto collecting ducts. /ts more specific to say
secretory end pieces instead of acini because |

***the word “acini” here refers to the secretory endpieces..

note that the secretory end pieces are tubular in mucussecreting
glands and spherical in serous secreting glands***

end pieces emptyinto the intercalated ducts, whichjoin to form the striated
ducts which emptyintocollecting ducts.
collecting ducts are either minor or major.
the major collecting ducts group together to pour the secretions into 1 main
excretory duct
v general organization of glands : secretory cells empty into > the lumen of
the secretory end pieces which lead to > intercalated ducts that group to
gather to form > striated ducts which group to gather into > minor collecting
ducts which group to gather into > major collecting ducts to pool the
secretions to > one main excretory duct then to the > oral cavity.

217 [Pag
 Salivary Glands
again:
"serous secretions: from the acini.
= mucussecretions: from the tubules.
= mixedsecretions: the tubules produce the mucus, and the demilunes
producethe serous, then both secretions mix in the lumen of the
secretory end piece.

* Myoepithelial cells: are

epithelial cells with contractile
ability, they wrap around the
secretory end pieces and
intercalated ducts making a
basket like shape
* When these cells contract,
they pushthe secretions from Tis picture is from “Oral Anatomyhistology and embryology4* edition” book,
the secretory end pieces page 288
towards the intercalated ducts, and from the intercalated ducts towards the
striated ducts.

o All the following is about the picture below.Thisis a histological

section from a mixed salivary gland and it showsthe secretory end pieces
mainly. Since the secretory end pieces are intralobular, So this section is
taken from a lobule.
© The serous acini look circular in shape and are stained (notclear).
o In this section, we can see that we have mostly mucus cells, but it’s still not
possible to tell whether the whole gland is mostly serous or mucus; because
the section shows a small part of the gland only.

o It’s difficult to find fully mucus secretory end piecesin a mixed salivary gland,
since the tubules often have serous demilunes on them.

220| Pag
 Salivary Glands o

© Inhematoxylin and eosin stain, the mucus cells look almost clear (foamy
appearance) since they don’t take up the stain.
Y NOTE THAT:mucuscells look less clear thanfat cells in H&Estain.

o Why do mucuscells have foamy appearance in H&E stain?

v Because there are vacuolesinside eachcell, which contain highly
glycosylated mucin.
Y each vacuole is surroundedby a plasma membrane (which takes up the
stain) and has the mucin in the middle (which doesn’t take up the stain
and looks almostclear)... this will lead to the foamy appearance.

2-FunctionsofSaliva:

© Muci lubricant facilitating mastication, swallowing and speech.

Mucous film protects the mucosa and keepsit moist.
¢ Saliva brings substancesinto solution facilitating taste.
¢ Prevents bacterial aggregation.
« Lysozyme againstbacteria.
© Minerals actas buffer.

221 | Pag
[| Salivary Glands
© Epidermal growth factor (EGF): wound healing.
Mucosal immune system (IgA production).
¢ Amylaseaids in carbohydrate digestion

Salivary GlandsClassification

e Are classified according to size or secretion:

1. Size: major or minor.
2. Secretion: serous, mucous or mixed.

Majorsalivary glands are: parotid &

submandibular & sublingual.
¢ Minor salivary glands are absent from the

psoas tu ny 20aso HOE©ag

gingiva and the dorsum ofthe anterior 2/3 of
the tongue since there is no submucosa there
** wherever we don’t have submucosa we
don’t have minor salivary glands (the only
exception is the minor lingual gland which are
presentwithin the muscle itself, and its duct
open to the ventral surface of the tongue).

¢ Completely serous glands are: parotid (major gland) /Von Ebner (minor
gland which is just anterior to the sulcus terminalis)
© Completely mucusglands are: minor salivary glands in the posterior 1/3 of
the oral cavity (major NEVER
Y For example: minor salivary glands in the submucosa ofthe posterior
1/3 of the tongue,the posterior lateral region of the hard palate ,soft
palate ,palatoglossal and palatopharyngeal arches

222 | Pag
 Salivary Glands

Mixed glands: a// minor salivary glands in the anterior 2/3 and the sublingual
gland(major) are mixed but mainly mucus except submandibular
gland(major) mainly
is mixed (this only in the oral
cavity that is mixed but mainly serous)
Y For example: minor salivary glands in the submucosaofthe lip (labial
glands), cheek (buccal glands), floor of the mouth, anterior lingual
glands (within the substance of the muscles) and alveolar mucosa.

3-Salivary Secretion

Lowlevel of secretion throughoutthe day.

Large additions take place at meal times, since we need moresaliva at meal
times.
Average flow rate is 0.3ml/min.

Sublingual and minor glandssecrete saliva spontaneously, meaning that

they secrete without the need for neural stimulus.
Parotid and submandibular glands are completely nerve mediated, so the
glands need neural stimulus to start secreting.
Consequently, Secretion from the parotid and submandibular glands ceases
almost entirely during anaesthesia(if the anaesthesia affects the nerves
which supply these glands), however secretions from sublingual and minor
salivary glands will NOT be affected by anaesthetics.

Cells store and secrete proteins by granule exocytosis upon receiving a

signal.
Cells secrete proteins continuously by a vesicular mechanism, vesicles
travelling directly from Golgi complex to the plasma membrane which is
called Constitutive pathway.

223 | Pag
 Salivary Glands
> Nerve Supply
Sympathetic and parasympathetic fibers innervate the acini. (autonomic
system)
¢ Nerve endings beneath the basal lamina in direct contact with the cell
membrane (hypolemmal nervefibers).
© Other endings remain beneath the basal lamina (epilemmal nervefibers).
© Parasympathetic drive causes fluid formation.
© Sympathetic drive increases the output of preformed components.
¢ Both cause the contraction of myoepithelial cells.

> Duct System:

1. Intercalated ducts.
2. Striated ducts.
3. Collecting ducts.

1) Intercalated Ducts:
© Intercalated ducts lead from serous acini into striated ducts.
Compressed between acini (intralobular).
¢ Lined by cuboidal or flat epithelial cells.
¢ Prominent nuclei, scanty cytoplasm (appear dark).

Black arrows:intercalated duct

A: secretory endpiece /serous acinus

227 | Pag
| Salivary Glands

¢ Smooth luminal and basal cell surfaces (no

microvilli or any infoldings).
© Desmosomes between cells.
¢ Occasional granules.
e Limited number of organelles.
May act as stem cells to replacecells either
from the secretory end pieces or the nearby
striated duct.
© Several acini drain into each duct.
e Inthe parotid glands, they are long, narrow ns
and branching. (different from the The cell that makes thelumenofthe
submandibular gland) intercalated duct
¢ Consequently,it’s easier to find an intercalated duct in a section fromthe
parotid gland than from the submandibular gland; as it’s short.

2) Striated Ducts:
e Longer, moreactive than intercalated ducts.
© Large cytoplasm(light)
¢ Large, spherical, centrally located nucleus.
¢ Highly polarized cells.
¢ Microvilli on luminal surface.
* Striations on the basal surface.
© Striations represent infoldings in the cell
membrane.

228 | Pag
 ¢ Vertically aligned mitochondria between the
basal infoldings.
«¢ Desmosomes. ~
© Cells involved in active transport.
Electrolyte reabsorption (Na+ and Cl-) and
secretion (K+ and HCO3-).
¢ Reabsorption is against the concentration
gradient thus needs energy.
© Converting isotonic orslightly hypertonic fluid Basal side
into hypotonic (since Na+ and Cl- move from the paner
lumen toinside the cells) this is a cellfrom the wall of|
striated duct
Small secretory granules on the luminal side
contain EGF (epidermal growth factor) and Kallikrein (subgroup ofserine
protease)
e Less abundantin parotid compared to submandibular gland (harder to find
striated duct in the parotid gland)
© Striated ducts lead to the minor collecting(excretory) duct.

3) Collecting Ducts:
© Collecting ducts have a columnar unstriated layer.
¢ Inthe minorcollecting ducts,it’s simple columnar, and in the major,it’s
pseudostratified columnar epithelium.
@ May have a layer of basal cells, which is often incomplete (here we refer
to the major collecting duct only).
¢ The main excretory ductof the parotid has 2 layers:
i. Mucosa: includes epithelium (stratified columnar) +lamina propria.
ii. Outer connective tissue adventitia.
¢ Near the termination whereit emptied into the oral cavity, the lining
might become non-keratinized stratified squamous (same as the lining of

229 | Pag
a Salivary Glands

the oral cavity). Which implies to all ducts whetherit’s a main execratory
ductor major collecting duct.
© The main parotid ductis also called Stensen duct.
| second layer
{columnar

4) Myoepithelial Cells:
These contractile cells lie between the basal lamina and the membranes
of secretorycells and the intercalated ductcells.
Dendritic cells with radiating processes.
Longer around intercalated ducts with
fewer shorterprocesses.
They contractin response of
sympathetic and parasympathetic
stimulation.
Also called basketcells
Flat nucleus.
Few protein synthesizing organelles.
Numerous actin microfilaments 4-8,1m in diamter.
Desmosomeslink them tosecretory cells.
Gap junctions, hemidesmosomes with basal lamina.
They expresscytokeratin 14 (CK14), and this proves that these cells have
epithelial origin.

230 | Pag
 Salivary Glands a
¢ Functions:
sm moan oD . Accelerate theinitial outflow ofsaliva.
Reduceluminal volume.
Contribute to secretory pressure.
Support parenchyma.
Reduceback permeation offluid.
Helps overcome peripheral resistance.
Help secretory cells expel their content.
Milking of extracellular fluid and assisting its passage through tight
junctions.

5-Submandibular Gland:

« The second largest gland.

¢ The only mixed but mainly serous
gland (seromucous).
Serous: mucous acini 7:3 (70% serous
and 30% mucus). Which reflected to
the secretions.
¢ Has a capsule,like any salivary gland.
Its serous acini are similar to parotid.
¢ Inthe histological section in the picture on your right side, a different stain
was used (not H&E),in this stain, the mucus secretory end pieces appear pink
in color, while serous secretory end pieces appear brown (majority).
However,the fat cells appear clear regardless of the stain.

231] Pag
[| Salivary Glands

> Mu IIs
They have the same appearancein all glands.
Mucinous cells appear paler than serous cells.
The nuclei are compressed basally.
Serous demilunes: crescent shaped serous cells at the end of the mucus
tubules (they're also present in the sublingual and mixed minor salivary
glands).

reerenueCR MEG
PERMeerReese
Beran Ecc

Mucous cells stain with alcian blue and PAS(Periodic acid—Schiff) stain
but they don’t stain with H&E.
Serous cells have been shown to align with mucous cells around a
commonlumen.
Conventional tissue preparation leads to mucouscells pushing serous
cells aside towards the basal side ofthe acinus.
Distension of mucousgranules also pushes the nucleus basally.
MoreconspicuousGolgi apparatus in comparison to serous cells (more
carbohydrateslinked to proteins since Golgi apparatus are involved in
glycosylation and post-translational modifications).
Pale secretory granules (which contain mucin) that discharge by
exocytosis.

232 | Pag
 Salivary Glands a
> Duct System:
¢ Very similar to parotid glands.
¢ Intercalated ducts are much
shorter. Comparedto parotid
© Difficult to locate in routine
sections.
¢ Striated ducts are longer and more
obvious.
e The main excretory ductis called Wharton duct.

6-Sublingual Gland:

¢ Made up of one major sublingual gland in addition to 8-30 minor

glands.
e Each ofthe glands has its own duct system and emptying into the
sublingual fold in the floor of the mouth.
¢ The major part of the sublingual gland is a mixed, but mainly mucous
(mucoserous).
Havegroupsof pale mucous cells, occasional serous acini and
demilunes similar to submandibular gland.
¢ Less developed duct system.
¢ Nostriated ducts, no striations, consequently, its secretions are sodium
rich. So won’t be hypotonic
¢ Smaller parts drain into smaller ducts.
¢ The secretory end pieces empty into the lumen > intercalated ducts >.
intralobular minor collecting ducts > interlobular minor collecting
ducts > major collecting ducts > oral cavity.

233 | Pag
| Salivary Glands

v Assaid beforethatthis gland does NOThave a main execratory

duct but we have multiple major collecting ductfor it & for its
associated minor glands opening to the oral cavity.
¢ Insome references, they talk about Bartholin duct, which is the major
collecting duct of the largest part of the sublingual gland. However , this
duct doesn’t group all the major collecting ducts of the sublingual gland
with the associated minor glands.
Myoepithtiatcet

7- MinorSalivary Glands:
© Location: Buccal (submucosa ofthe cheeks), labial (oral side of thelip),_
palatal (submucosaofthe posterior later region of the hard palate and the
submucosa ofthe soft palate), palatoglossal (pharyngeal isthmus) and lingual
(the submucosaof the posterior 1/3 of the dorsal side of the tongue and in
the substance of the muscle in the anterior 1/3 & empties to the ventral
surface of the tongue).
¢ Inthe anteriorpart of the oral cavity, they’re mixed but mainly mucous.
¢ Inthe posterior region of the oral cavity, they’re completely mucus.
© Von Ebner’s (associated with the circumvallate papillae) glands are serous.

234| Pag
 Salivary Glands

In the picture:
1. Picture A is from the hard palate, and B from
the tongue dorsum
. EP: keratinized stratified squamous
epithelium, andtherete ridges are square in
shape,indicating that this section is from the
hard palate
. LP: lamina propria
. SM: submucosa
. Muc: mucusminorsalivary glands.
. B: palatine bone
. VE: von Ebner’s gland
8. M: muscle fibers
The arrow: the direction ofthe posterior1/3 of the
tongue dorsum,and the oppositeside is the
anterior 2/3

8- Clinical Considerations:

© Xerostomia: (dry mouth/significant decreasein salivary secretions)

° Causes:
1. Old age. because of replacement of the parenchyma by fat cells
2. Side effects of some medication.
3. Radiotherapyif used in the head and neck region will lead to
irreversible damagesofsalivary glands.
4. Sjogren’s syndrome, which is an autoimmune disease that leads to
damageofsalivary and lacrimal glands. (so the damageisirreversible)

© Xerostomia results in candidal infections, severe periodontal diseases

and caries.
235 | Pag
 Salivary Glands

© Solution:
a) Artificial saliva (if the damage was irreversible).
b) Sialoloth/Sialolithiasis: condition involving the formation of stones
within the ducts of the major salivary glands (particularly the
submandibular and parotid, since they have one main excretory
duct), these stones haveto be surgically removed, because they
cause pain and lead to serious inflammations since the salivais
retained in the gland and cannotbe excreted.
c) If it was a result of a medication, then we changeit to a different
one with less side effects.

Past papersof this chapter ©

From 016:
1) Xerostomia is causedbyall thefollowing except
a) old age
b) radiotherapy for head and neck
©) sjogren’s syndrome
d)sialolothsof sth
e) noneofthe above
Ans:e

2) The major salivary glandsare present in

a) parotid
b) submandibular
c) sublingual
d)all of the above
Ans: d
236 | Pag
 Salivary Glands

3) Allaretrue aboutstriated ductsexcept

a) highly polarized
b)electrolyte reabsorption (Na+ andCl-)
¢) secretion of(K+ and HCO3-)
d) noneofthe above
e) can'tremember
Ans: d

From 015:
4) Striated duct is formed by:
Ans: simple columnarepithelium.

5) submucosaoftheposterior hard palatelateralto the midlinecontains:

Ans: mucousminorsalivary glands.

6) All thefollowing are intralobular ducts, EXCEPT :

Ans: collecting ducts.

7) mixedsalivary gland acini has:

Ans: serous demilunes.

237| Pag
 Temporomandibular joint %\y)

Lecture outline:
1- Gross Anatomyof the TMJ foteacerticunaedise
2- Articular surfaces
3- Intra-articular disc
4- Synovial membrane
5- Developing condyle
6- Clinical considerations
Temporomandibular joint
(TMJ)

Now,wewill start explaining the matter in details.

Temporomandibular joint

* Synovial articulation between the mandible and the cranium, more

specifically it is an articulation betweenthe headof the condyle (mandibular
condyle) and the mandibular fossa (whichis depression in the temporal
bone).

Y Cranium skull.
¥ So Craniomandibular joint is another name for temporomandibular
joint.

* Hinge joint with gliding movements.

* The articular surfaces are coveredwith fibrous tissue (intramembranous

bone formation which meansthe bonesthat contribute to the formation of

238
 Temporomandibular

Temporomandibularjoint *both the condylar process and temporal bone*

are formed by intramembranousossification).

* The joint cavity is divided into twojoint spaces by an intra-articular disc;

forming an upper and lower compartments.

* Temporomandibular joint is surrounded by capsule.

1- Gross Anatomy:
Components of temporomandibular joint:
* The mandibular fossa = glenoid fossa
The mandibular condyle = head of the condyle.
Capsule
Temporomandibular ligament

Accessory ligaments
Intra-articular disc

1- The mandibular fossa

+ An oval depression in the temporal bone.
* Anterior to the external acoustic meatus.
* Variations in the curvature (thought to berelated to the different types of
occlusion between people)
* The intra-articular disc molds the shape between the fossa and the condyle.

239 Copyriant S
 Temporomandibular joint

2-The mandibular condyle

* HasVariationsin size and shape.

* The longaxis is NOTat right angles with the ramus.
* The articular surfaces are the convex anterior and superior surfaces of
the condyle.
+ Joins the ramus through the neck ofthe condyle.

Pic from the

Tresor
Puena ts
Mandible like

eae}
eon NEI ares

240
| Temporomandibularjoint
3- Capsule
* Thin cuff of fibrous tissue.
* Doesnotlimit mandibular movements, too weak to provide support to
the joint.
* Attached to the glenoid fossa, articular eminence and the neck of the
condyle.
* Posteriorly it is associated with the connectivetissue of the
interarticular disc.
+ Internally,it is attached to the interarticular disc and lined by the
synovial membrane.
* Richly innervated.

4- Synovial membrane
* The synovial membrane lines the inner surfaces if the capsule and the
margins ofthe disc.

* Does notcover the articular surfaces.

* Secretes the synovial fluid that:

1. Fills the joint cavities.

2. Lubricates the joint.

3. Nutritive functions.

241
 Temporomandibular j «ll

Posteriorly the disc divides into two

lamina (superior laminae and
inferior laminae) that’s why this
Mandibular fossa: zone called bilaminar zone

Articular disc
Anteriorly the disc is
bound to a muscle called
lateral pterygoid muscle

Parotid gland

Y Note: the lateral pterygoid muscle plays a keyrolein initiation of

opening ofthe oral cavity; when it contractsit pulls the disc & the
head of the condyle forward and downward whichcauses the
initiation of mouth opening, then another muscle continues the
opening action whichis the digastric muscle.

5- Temporomandibular ligament
- Temporomandibular ligament is the MAIN & STRONGESTSligament that
provides support to the temporomandibular joint.

* Strengthens the joint capsule.

+ Restricts distal and inferior mandibular movements.

* Resists dislocation during functional movements.

* Origin: lateral surface of articular eminence.

* Insertion: posterior surface of condyle.

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| Temporomandibularjoint

‘Sphenomandibular ligament
Lateral (temporomandibular) ligament
Joint capsule

Stylomandibularligament
Mandibular nerve
& otic ganglion

Lingual nerve“
jhenomandibular ligament’
Jlomandibular ligament

6- Accessory ligaments
Includes:
1. Stylomandibular ligament
Extends from the styloid process to the angle of the mandible.
2. Sphenomandibular ligament(seenbetter from "inside" the medial view)
Extends from the spine of the sphenoid bone to the lingula near the
mandibular foramen (which is the opening of the inferior alveolar
canal).
3. Pterygomandibular raphe
Extends from the pterygoid hamulus to the retromolar region of the
mandible.

4. Retinacular ligament

Extendsfrom the articular eminenceinto the fascia of the masseter

muscle.
243
 Temporomandibular joint

7- intra-articular disc
* Densefibrous.
* Peripheral bloodvessels only. So no blood vessels in the center.
* Upper surface cocavo-convex from the front to the back; becauseit
molds the shape ofthe glenoid fossa & articular eminence.
(Like this) \_)
* Lower surface is concave; as the head of the condyle against it is
convex.
* Thinnest centrally (so higher chanceof perforation), thickest
posteriorly.
* Lateral half thinner than medial half.
Articular
eminence
This is a longitudinal
section of the TMJ.

The mandibleis
slightly depressed
which meansthe
mouthis slightly
opened.
Condyle’ nr©209, No ote
8- Intra-articular disc portions:
* Anterior

* Collagen fibres run anterio-posteriorly and medio-laterally.

* Intermediate:

* Thinnest.
* In contact with the articular surface of the condyle.

244
 Temporomandibular

* Collagen fibres run only anterio-posteriorly.

Posterior

* Collagen fibres run anterio-posteriorly and medio-laterally.

On the peripheries, it merges with the capsule

Anteriorly, attached via fibrous bands to the
anterior margin of the articular eminence above,
and to the anterior margin of the condyle below.
Medially and laterally attached to the capsule
Posteriorly attached to the capsule via bilaminar
zone: superior and inferior laminae.

+ Nerves:
* The TMJis richly innervated.

The innervation of the TMJ includes:

= Some of them are Proprioceptive nerve endings which are

involved in mechanicalor pressure sensation (reflex control of
mastication).
For example whenweaccidentally chew in something very hard >
the pressurewill increase dramatically inside the TMJ > this
pressurewill be sensed bythe proprioceptive nerve endings > send
a messageto central nervous system > which will send an order to
the muscles responsible for chewing to stop for protection.
= Others are Free nerve endings which is involved in nociception
(= pain sensation).
= Auriculotemporal, masseteric and deep temporal nerves (divisions
of the mandibular division of the trigeminal nerve).

245
 Temporomandibular joint Ll

2- Articular Surfaces:
* Histologically The head of the condyle has four layers:

1. The mostsuperficial articular surface, composedoffibrous tissue.

(collagen fibres and fibroblast). collagenfibres more thanfibroblast
Its called the Fibrous Zone.

2. Acellular zone whereproliferation occurs. (proliferative zone or cellular

zone)
3. A fibrous layer with a variable appearance,cartilagelike cells,
fibrocartilagenous layer.

4. Calcified cartilage directly covering the bone.

* The articular surface of the mandibular fossa is very similar, only thinner.

|— Articular disk ——> the

joint
|— Articular zone ———>=fibrous
>— Proliferative zone
[— Fibrocartilaginous zone

|__ Calcified cartil

alcified cartilage ——> darker
caries

t— Subarticular bone —> |

Copyright © 2003, Mosby, Inc., All ights reserved.

246
 Temporomandibularjoint

|— Temporal bone
| cartilage
|— Fibrocartilaginous zone Histological section of
thearticular surface of
|~ Proliferative zone the mandibular fossa
-— Articular zone All layers are the same
except that the articular
zoneis thicker & the
othersare thinner

|~ Articular disk
J copyright © 2003, Mosby, nc, All rights reserved.

3- TheIntra-Articular Disc:
* Dense collagenous fibrous tissue.

* Fibres run in anterio-posterior direction in the middle.

* Medio-lateral, and superio-inferior directions as well at the anterior and

posterior ends. ( So this fibres runs in all directions)

* More convoluted appearance anteriorly and posteriorly; which provide the

fibres moreability to withstand stretching so they don’t torn.

247
 Temporomandibular joi sill

* fibres on the peripheries have Circumferential

arrangement.

* Under very high magnification of thesefibres of intra-

articular disc we see Dark and light bands (15-20,1m)
indicate crimpsor wavinessofthe fibres.
* Crimps are importantfor the biomechanical properties
of the connective tissue; as it have greater ability to
withstand stritching.

«+ Chemical Composition ofthe disk:

1- fibrous matrix:
Collagen type | (80% ofdry weight).

Collagen typeIII (small amounts).

Collagen typeII (localized areas of fibrocartilage).

= Sometimes wefind fibrocartilage inside the articular disk, that's
whywefind collagen type II; As collagentypeII is the cartilage
collagen.

Elastin fibres.
2- Ground substance(5% of dry weight):
= 2/3 chondroitin sulphate. (majority)
= 1/3 dermatan sulphate.
= Traces of hyaluronan and heparan sulphate.

248
 Temporomandibular joint

Cell population:
More abundantatbirth.

Variations between flattened and rounded cells; the flattened cells are
thefibroblasts that producecollagen & the roundedarethe cartilage
like cells that producecollagentypeII cartilage .

Moderate amountsof endoplasmic reticulum; which means they are

involved in protein synthesis.

Intermediate filaments.

Plasma membranesadjacent to extracellular collagen fibres.

Are the cells name is fibroblasts or fibrocytes?

Fibroblasts (active cells) or fibrocytes (less active, non dividing cells due
to aging). And as they are notreally active then mustbe called
fibrocytes, butit's still called fibroblasts in textbooks.

* Fibrocartilagenousareas:
Rounded appearance ofcells.

Reminiscent ofcartilage cells in lacunae. Look similar to chondrocytes.

Interface between cells and lacunae stains with alcian blue and
toluidine blue; as these stains are used to stain collagen type II.

Collagen typeIl.

Pericellular matrix with microfilamentous material, associated with

ageing in the mouse.

v Thepresence offibrocartilagenous areas have been proven in

laboratory mice to be a sign of aging; which is likely to be the same
in humans. (So¢ in age = ¢ in the ofareas).

Lack ofpericellular capsule.

249
| Temporomandibular joint

6- Clinical Considerations:
* Arthritis of the TMJ:
1. Rheumatoid arthritis, (which affect the small join) and as the TMJ is
considered a small joint so it is Most common tohaveit.
2. Osteoarthritis. (affect the large joint)

+ Internal derangement:

= Could Include:

a. Displacementof the disc (anteromedially);

when this happen wewill have 2 scenarios either

1) clicking in the joint which is called anterior disc displacement

with reduction which means the disc becomesan obstacle but
the condyle can bypass the disc; when the bypass happens we
will hear clicking and the normal mouth opening won't be
affected.
2) anterior disc displacement without reduction; which means the
disc is anteriorly displaced and the condyle can't bypassit so we
will have limited mouth opening. And won't haveclicking sounds.

b. Pain.

c. Clicking.
d. Restriction of mandibular movement.

e. Degenerative changes, changein the disc shape;if left untreated it may

lead to ~

f. Eventual perforation.

g. Degeneration in articular surfaces; which is associated with rheumatoid

arthritis & osteoarthriris.

If any ofthesesigns or symptoms arepresent weshould refer the

patient to the maxillofacial syrgeon.

253
 Temporomandibular j 1

* Occlusal changes lead to changes in the TMJ.

For example:

1. when weextract one ofthe teeth, this will leave a spaceif not replaced
the teethwill start to close the spaceby tipping and drifting, which will
disrupt the whole occlusion .

2. If we havea filling, a crown or a bridge that is not done properly,it will

affect the occlusion and subsequently the TMJ.

254
 Past papersof this chapter ©

From 016
1) Abouttheclinical considerationsof the TMJ all of the following are true except:
a) displacement ofthedisc (ateromedially)
b) pain
©) clicking
d)restriction of mandibular movement
e) noneofthe above
Answer: E

2) Wrongaboutsynovial membrane:
Answer: It cover the articular surface

3) Wrongaboutthe capsule in the TMJ:

Answer:it’s poorly innervated

4) Wrongaboutprimary and secondary ossification:

Answer: Secondary hasinherit growth potential

From 015:
5) One oftheseis the characteristics of Condyle cartilage?
Answer: the cartilagewill still active until age of 20 (adult)

6) "secondarycartilage" has its name according to :

Answer: It appears after mickels cartilage (not the first formedcartilage in thetissue).

7) Whatis the site of ptrigoid compared with TMJ ?

Answer: anterior to it
8) Oneof thefollowingstatementsis incorrect about the Meckel's cartilage:
Answer: acts as a scaffold for the bodyof the mandible to form endochondrally
(intramembranously not endochondrally)

9) Endochondral ossification occursat the following sites:

Answer: condylar process of the mandible

10) Intramembranous ossification occurs at the following sites:

Answer:body of the mandible
Facebook: Hemmeh Asnan